WHO Systems Thinking 9789241563895 - Eng

SYSTEMS
THINKING
for Health Systems
Strengthening
SYSTEMS
THINKING
for Health Systems
Strengthening
WHO Library Cataloguing-in-Publication Data
Systems thinking for health systems strengthening / edited by Don de Savigny and Taghreed Adam.
1.Delivery of health care – organization and administration. 2.Delivery of health care – trends. 3.Systems theory.
4.Health services research. 5.Cooperative behavior. 6.Health policy. I.de Savigny, Donald. II.Adam, Taghreed. III.Alliance
for Health Policy and Systems Research. IV.World Health Organization.
ISBN 978 92 4 156389 5 (NLM classification: W 84)
© World Health Organization 2009
All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia,
1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce
or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address
(fax: +41 22 791 4806; e-mail: permissions@who.int).
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part
of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation
of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health
Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are
distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the
p u b l i s h e d m a t e r i a l i s b e i n g d i s t r i b u t e d w i t h o u t wa r ra n t y o f a n y k i n d , e i t h e r e x p r e s s e d o r i m p l i e d . Th e r e s p o n s i b i l i t y
for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable
for damages arising from its use.
Printed in France
Designed by Capria
Design Consultant: James B. Williams
Suggested citation: Don de Savigny and Taghreed Adam (Eds). Systems thinking for health systems strengthening. Alliance for Health Policy
and Systems Research, WHO, 2009.
2 SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

Contents
Contents
Acknowledgments ............................................................................................................................................ 11
Preface .................................................................................................................................................................. 15
Executive Summary ......................................................................................................................................... 19
Acronyms .............................................................................................................................................................. 25
Chapter 1
Systems thinking for health systems strengthening: An introduction .................................. 27
Introduction to the Report ............................................................................................................................... 29
Key terms and terminology .............................................................................................................................. 30
Overview of the Report .................................................................................................................................... 35
Chapter 2
Systems thinking: What it is and what it means for health systems .................................... 37
Objectives of the Chapter ................................................................................................................................ 39
Systems thinking .............................................................................................................................................. 39
Bringing the system into focus with a systems thinking lens ........................................................................... 40
Systems thinking: A paradigm shift .................................................................................................................. 43
System stakeholder networks ........................................................................................................................... 44
Another view of interventions .......................................................................................................................... 45
Intervening at high leverage points in the system ............................................................................................ 47
Implications of systems thinking for designing and evaluating health interventions ......................................... 47
Chapter 3
Systems thinking: Applying a systems perspective to design
and evaluate health systems interventions ........................................................................................ 49
Introduction ...................................................................................................................................................... 51
Systems thinking: A case illustration ................................................................................................................ 51
Ten Steps to Systems Thinking ......................................................................................................................... 54
Part I: The intervention design .......................................................................................................................... 55
Part II: The evaluation design ........................................................................................................................... 60
Conclusion ....................................................................................................................................................... 71
CONTENTS 5
Chapter 4
Systems thinking for health systems: Challenges
and opportunities in real-world settings ............................................................................................. 73
Introduction ..................................................................................................................................................... 75
Part I: Select challenges in applying a systems perspective .............................................................................. 75
1. Aligning policies, priorities and perspectives among donors
and national policy-makers ..................................................................................................................... 76
2. Managing and coordinating partnerships and expectations among
system stakeholders ................................................................................................................................ 78
3. Implementing and fostering ownership of interventions at the national
and sub-national level ............................................................................................................................ 78
4. Building capacity at the country level to apply a systems analytic perspective ....................................... 80
Part II: Innovative approaches to applying the systems perspective ................................................................. 82
1. Convening multiple constituencies to conceptualize, design
and evaluate different strategies ............................................................................................................ 82
2. Applying the whole systems view ........................................................................................................... 83
3. Developing knowledge translation processes .......................................................................................... 84
4. Encouraging an increased national understanding of health systems research
and increased global support for strengthening capacity in health systems research ............................. 86
Conclusion ....................................................................................................................................................... 86
Chapter 5
Systems thinking for health systems strengthening: Moving forward ................................. 87
The growing focus on health systems .............................................................................................................. 89
Schools of thought and experience .................................................................................................................. 90
Moving forward ............................................................................................................................................... 92
Wrapping up .................................................................................................................................................... 94
Reference List .............................................................................................................................................. 95
Alliance Board members ........................................................................................................................105
Alliance Scientific and Technical Advisory Committee members ..........................................105

List of Figures
Figure 1.1 The building blocks of the health system: aims and attributes ............................................................ 31
Figure 1.2 The dynamic architecture and interconnectedness of the health system building blocks ...................... 32
Figure 1.3 A spectrum of interventions and their potential for system-wide effects ............................................. 34
Figure 3.1 More conventional pathway from P4P financing intervention to expected effects ............................... 53
Figure 3.2 Conceptual pathway for the P4P intervention using a systems perspective ......................................... 58
Figure 3.3 Major moments in Steps 1–5 .............................................................................................................. 59
Figure 3.4 Key components and generic research questions for evaluations ......................................................... 61
Figure 3.5 Socioeconomic distribution of households by launch of insecticide-treated nets (ITNs)
voucher scheme in the United Republic of Tanzania ............................................................................ 70
List of Tables
Table 2.1 Skills of systems thinking ..................................................................................................................... 43
Table 2.2 Typical system-level interventions targeting individual or multiple building blocks ............................... 46
Table 3.1 Prioritized potential system-wide effects of the P4P intervention ......................................................... 57
Table 3.2 A selection of research questions, indicators and data sources for the P4P intervention ..................... 62
Table 3.3 Summary of characteristics for optional evaluation design choices for the P4P intervention ................ 68
List of Boxes
Box 1.1 Goals of this Report ............................................................................................................................. 29
Box 1.2 Four revolutions that will transform health and health systems ........................................................... 33
Box 1.3 Indicators and tools for monitoring changes in health systems ........................................................... 35
Box 2.1 Common systems characteristics ......................................................................................................... 40

Box 2.2 System behaviour ................................................................................................................................. 40
Box 2.3 The connections and consequences of systems thinking ...................................................................... 42
Box 2.4 System stakeholder networks ............................................................................................................... 44
Box 2.5 Systems thinking elements ................................................................................................................... 45
Box 3.1 A pay-for-performance intervention – An illustrative example .............................................................. 52

Box 3.2 Ten Steps to Systems Thinking: Applying a systems perspective
in the design and evaluation of interventions ...................................................................................... 54
Box 3.3 The P4P Intervention – Convening stakeholders .................................................................................. 55
Box 3.4 The P4P Intervention – Brainstorming .................................................................................................. 56
Box 3.5 The P4P Intervention – Redesign ......................................................................................................... 59
Box 3.6 The P4P Intervention – Probability design ........................................................................................... 66
Box 3.7 The P4P Intervention – Evaluation type ............................................................................................... 67
Box 3.8 Non-random roll out of interventions and the timing of evaluations ................................................... 69
CONTENTS 7
List of Boxes (CONTINUED)
Box 4.1 Select challenges in applying a systems perspective ............................................................................ 75

Box 4.2 Defining health systems stewards ........................................................................................................ 76
Box 4.3 Defining "street-level" policy implementers ......................................................................................... 79
Box 4.4 Initiative on the Study and Implementation of Systems (ISIS) .............................................................. 82
Box 4.5 Making Sound Choices on evidence-informed policy-making .............................................................. 84
Box 4.6 Interaction between researchers and policy-makers on a road traffic policy in Malaysia ...................... 85
Box 5.1 Summary of the Ten Steps to Systems Thinking for health systems strengthening ............................... 90
Box 5.2 Example of system-wide effects of a system-wide intervention ............................................................ 91

Acknowledgments
Acknowledgments
This Flagship Report is the joint product of a number of people, and the Alliance
wishes to thank them for their input.
Editors: Don de Savigny and Taghreed Adam
Principal authors:
Chapter 1. Systems thinking for health systems strengthening: An introduction
Don de Savigny and Taghreed Adam
Chapter 2. Systems thinking: What it is and what it means for health systems
Don de Savigny, Taghreed Adam, Sandy Campbell and Allan Best
Chapter 3. Systems thinking: Applying a systems perspective to design and evaluate health systems interventions
Don de Savigny, Josephine Borghi, Ricarda Windisch, Alan Shiell and Taghreed Adam
Chapter 4. Systems thinking for health systems: Challenges and opportunities in real-world settings
Taghreed Adam, Sangeeta Mookherji, Sandy Campbell, Graham Reid, Lucy Gilson and Don de Savigny
Chapter 5. Systems thinking for health systems strengthening: Moving forward

Don de Savigny
Web Annex. Evaluation of interventions with system-wide effects in developing countries: Exploratory review
( http://www.who.int/alliance-hpsr/resources/en/ )
Dominique Guinot, Barbara Koloshuk, Kaspar Wyss and Taghreed Adam
Valuable technical inputs and review comments were provided by various people
through participation at a brainstorming workshop (September 2008), an experts
consultation meeting (April 2009) and reviewing chapter drafts (in alphabetical order):
Irene Agyepong Sennen Hounton Mark Petticrew
Anwer Aqil Aklilu Kidanu Kent Ranson
Sara Bennett Soonman Kwon Graham Reid
Allan Best Mary Ann Lansang John-Arne Röttingen
David Bishai John Lavis Sarah Russel
Valerie Crowell Daniel Low-Beer Alan Shiell
Marjolein Dieleman Prasanta Mahapatra Terry Smutylo
Shams El-Arifeen Lindiwe Makubalo Göran Tomson
David Evans Anne Mills Phyllida Travis
Lucy Gilson David Peters Cesar Victora
Sandy Campbell was copy editor and Lydia Al Khudri managed the production of the report.
ACKNOWLEDGMENTS 11
Preface
Preface
Strong health systems are fundamental if we are to improve health outcomes and accelerate progress towards
the Millennium Development Goals of reducing maternal and child mortality, and combating HIV, malaria and other
diseases. At a time when economic downturn, a new influenza pandemic, and climate change add to the challenges
of meeting those goals, the need for robust health systems is more acute than ever.
Often, however, health system strengthening seems a distant, even abstract aim. This should not and need not be the case.
I therefore welcome this Flagship Report from the Alliance for Health Policy and Systems Research, which offers a fresh
and practical approach to strengthening health systems through "systems thinking". This powerful tool first decodes
the complexity of a health system, and then applies that understanding to design better interventions to strengthen
systems, increase coverage, and improve health.
In its “Ten Steps to Systems Thinking,” this Report shows how we can better capture the wisdom of diverse stakeholders
in designing solutions to system problems. It suggests ways to more realistically forecast how health systems might
respond to strengthening interventions, while also exploring potential synergies and dangers among those interventions.
Lastly, it shows how better evaluations of health system strengthening initiatives can yield valuable lessons about
what works, how it works and for whom.
Health systems strengthening is rising on political agendas worldwide. Precise and nuanced knowledge and understanding
of what constitutes an effective health system is growing all the time – a phenomenon that is well reflected
in this Report. This Flagship Report will deepen understanding and stimulate fresh thinking among stewards
of health systems, health systems researchers, and development partners. I look forward to seeing its results.
Dr Margaret Chan
Director-General, World Health Organization, Geneva
November 2009
PREFACE 15
Executive Summary
Executive Summary
The Problem
Despite strong global consensus on the need to strengthen health systems, there is no established framework for doing
so in developing countries, and no formula to apply or package of interventions to implement. Many health systems simply
lack the capacity to measure or understand their own weaknesses and constraints, which effectively leaves policy-makers
without scientifically sound ideas of what they can and should actually strengthen. Within such unmapped and
misunderstood systems, interventions – even the very simplest – often fail to achieve their goals. This is not necessarily due
to any inherent flaw in the intervention itself but rather to the often unpredictable behaviour of the system around it.
Every intervention, from the simplest to the most complex, has an effect on the overall system, and the overall system
has an effect on every intervention.
As investments in health are expanded in low- and middle-income countries, and as funders increasingly support broader
initiatives for health system strengthening, we need to know not only what works but what works for whom and under
what circumstances. If we accept that no intervention is simple, and that every act of intervening has effects – intended
and unintended – across the system, then it is imperative that we begin to understand the full range of those effects
in order to mitigate any negative behaviour and to amplify any possible synergies. We must know the system in order
to strengthen it – and from that base we can design better interventions and evaluations, for both health systems
strengthening interventions and for interventions targeting specific diseases or conditions but with the potential of having
system-wide effects.
How we design those interventions and evaluate their effects is the challenge at the heart of this Report.
Systems Thinking
To understand and appreciate the relationships within systems, several recent projects have adopted systems thinking
to tackle complex health problems and risk factors – in tobacco control, obesity and tuberculosis. On a broader level,
however, systems thinking has huge and untapped potential, first in deciphering the complexity of an entire health system,
and then in applying this understanding to design and evaluate interventions that improve health and health equity.
Systems thinking can provide a way forward for operating more successfully and effectively in complex, real-world settings.
It can open powerful pathways to identifying and resolving health system challenges, and as such is a crucial ingredient
for any health system strengthening effort.
Systems thinking works to reveal the underlying characteristics and relationships of systems. Work in fields as diverse
as engineering, economics and ecology shows systems to be constantly changing, with components that are tightly
connected and highly sensitive to change elsewhere in the system. They are non-linear, unpredictable and resistant
to change, with seemingly obvious solutions sometimes worsening a problem. Systems are dynamic architectures
of interactions and synergies. WHO’s framework of health system building blocks effectively describes six sub-systems
of an overall health system architecture. Anticipating how an intervention might flow through, react with, and impinge
on these sub-systems is crucial and forms the opportunity to apply systems thinking in a constructive way.
EXECUTIVE SUMMARY 19
Applying Systems Thinking
Systems thinking provides a deliberate and comprehensive suite of tools and approaches to map, measure and understand
these dynamics. In this Report, we propose “Ten Steps to Systems Thinking” for real-world guidance in applying such
an approach in the health system. We use a major contemporary health financing intervention as a case illustration
to demonstrate how a broad partnership of stakeholders can deliver a richer understanding of the implications
of the intervention, including how the system will react, respond and change, along with what synergies can be harnessed,
and what negative emergent behaviour should be mitigated. We can then apply this understanding to a safer and more
robust intervention design and an evaluation that goes beyond the usual “input-blackbox-output” paradigm to one
that accounts for system behaviour. The systems thinking approach connects intervention design and evaluation more
explicitly, both to each other and to the health system framework.
TEN STEPS TO SYSTEMS THINKING IN THE HEALTH SYSTEM

I. Intervention Design II. Evaluation Design
1. Convene stakeholders 5. Determine indicators
2. Collectively brainstorm 6. Choose methods
3. Conceptualize effects 7. Select design
4. Adapt and redesign 8. Develop plan
9. Set budget
10. Source funding.
Challenges, Opportunities and Moving Forward

Many practitioners may dismiss systems thinking as too complicated or unsuited for any practical purpose or application.
While the pressures and dynamics of actual situations may block or blur the systems perspective, we argue that the timing
for applying such an approach has never been better. Many developing countries are looking to scale-up "what works"
through major systems strengthening investments. With leadership, conviction and commitment, systems thinking
can accelerate the strengthening of systems better able to produce health with equity and deliver interventions
to those in need.
Systems thinking is not a panacea. Its application does not mean that resolving problems and weaknesses will come easily
or naturally or without overcoming the inertia of the established way of doing things. But it will identify, with more
precision, where some of the true blockages and challenges lie. It will help to:
1) explore these problems from a systems perspective;
2) show potentials of solutions that work across sub-systems;
3) promote dynamic networks of diverse stakeholders;
4) inspire learning; and
5) foster more system-wide planning, evaluation and research.

And it will increase the likelihood that health system strengthening investments and interventions will be effective.
The more often and more comprehensively the actors and components of the system can talk to each other from within
a common framework – communicating, sharing, problem-solving – the better chance any initiative to strengthen health
systems has. Real progress will undoubtedly require time, significant change, and momentum to build capacity across
the system. However, the change is necessary – and needed now.
The Report therefore speaks to health system stewards, researchers, and funders. It maps out a set of strategies and activities
to harness systems thinking approaches, to link them to these emerging opportunities, and to promote systems thinking
as the norm in the design and evaluation of interventions in health systems.
But, the final message is to the funders of health system strengthening and health systems research who will need to recognize
the potential in these opportunities, be prepared to take risks in investing in such innovations, and play an active role in both
driving and following this agenda towards more systemic and evidence-informed health development.
EXECUTIVE SUMMARY 21
Acronyms
Acronyms
AHPSR Alliance for Health Policy and Systems Research
ANC Ante-natal Care
ART Anti-retroviral Therapy
CCT Conditional Cash Transfer
COHRED Council on Health Research for Development
DECIPHer Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement
EPI Expanded Programme for Immunization
FGDs Focus Group Discussions
HIC High-Income Country
HIS Health Information System
HIV/AIDS Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome
HMIS Health Management Information System
HMN Health Metrics Network
HSR Health Systems Research
IMCI Integrated Management of Childhood Illnesses
ITN Insecticide-treated Mosquito Net
LMIC Low- and Middle-income Country
MDGs Millennium Development Goals
P4P Pay-for-Performance (called both pay- and paying-for-performance in Chapter 3)
PAHO Pan American Health Organization
PBF Performance-based Funding
PHC Primary Health Care
RCTs Randomized Controlled Trials
SES Socio-economic Status
ST Systems Thinking
SWAps Sector-wide Approaches
TB DOTS Directly Observed Treatment for Tuberculosis – short course
TNVS Tanzania National Voucher Scheme
UNDP United Nations Development Programme
UNICEF United Nations Children’s Fund
WB World Bank
WHO World Health Organization
ACRONYMS 25
1
Systems thinking for health
systems strengthening:
An introduction
Flagship Report Series
The Alliance for Health Policy and Systems Research (“the Alliance”) is an international
collaboration based within WHO Geneva. Its primary goal is to promote the generation
and use of health policy and systems research as a means to improve health and health
systems in developing countries. The Alliance’s Flagship Report Series is a key instrument in
promoting innovative ideas that address current gaps or challenges and stimulating
debate on a priority topic identified by stakeholders in the field.
The first Flagship Report was 2004’s “Strengthening health systems: the role and promise of
policy and systems research,” with the principal goal of increasing knowledge on health
systems and applying that knowledge to strengthen health systems. The second Report,
produced in 2007, was “Sound Choices: enhancing capacity for evidence-informed health
policy,” which analyzed capacity constraints in linking research and policy processes. This
third Report knits together the earlier work by accelerating a more realistic understanding of
what works in strengthening health systems, for whom, and under what circumstances. Its
primary goal is to catalyze new conceptual thinking on health systems, system-level
interventions, and health system strengthening.
"For the first time, public health has commitment, resources, and powerful
interventions. What is missing is this. The power of these interventions is not
matched by the power of health systems to deliver them to those in greatest need,
on an adequate scale, in time. This lack of capacity arises … in part, from the fact
that research on health systems has been so badly neglected and underfunded.”
Dr Margaret Chan, Director-General, WHO. 29 October 2007
Introduction to the Report

The challenges of meeting the Millennium In many cases, the fundamental problem lies with
Development Goals (MDGs) for health remain the broader health system and its ability
formidable. While the current decade has seen to deliver interventions to those who need them.
significant advances in the health sector of low- We a k n e s s e s a n d o b s t a c l e s e x i s t a c r o s s
and middle-income countries, this progress has the system, including overall stewardship and
been slower than expected (1). Despite a strong management issues; critical supply-side issues
range of health interventions that can prevent such as human resources, infrastructure,
much of the burden of disease in the poorest information, and service provision; and demand-
countries – with ever-improving interventions in side issues such as people’s participation,
the pipeline – effective coverage of these knowledge and behaviour (5;6). Even more,
interventions is expanding too slowly (2;3) and specific losses in health intervention efficacy due
health inequities are widening (4). Cost-effective to health systems delivery issues are often grossly
interventions – when available – are both underestimated (7).
inadequately provided and underused (1).
BOX 1.1 GOALS OF THIS REPORT
Over 2008, wide global consultation revealed considerable interest and frustration among
researchers, funders and policy-makers around our limited understanding of what works in
health systems strengthening. In this current Flagship Report we introduce and discuss
the merits of employing a systems thinking approach in order to catalyze conceptual thinking
regarding health systems, system-level interventions, and evaluations of health system
strengthening. The Report sets out to answer the following broad questions:
n
What is systems thinking and how can researchers and policy-makers apply it?
n
How can we use this perspective to better understand and exploit the synergies among
interventions to strengthen health systems?
n
How can systems thinking contribute to better evaluations of these system-level
interventions?
This Report argues that a stronger systems perspective among designers, implementers, stewards
and funders is a critical component in strengthening overall health-sector development in low- and
middle-income countries.
CHAPTER 1 AN INTRODUCTION 29
Systemic factors and their effects are poorly It has huge potential, first in decoding
studied and evaluated. Few health systems the complexity of a health system, and then in
have the capacity to measure or understand using this understanding to design and evaluate
their strengths and weaknesses,especially interventions that maximize health and health
in regard to equity, effectiveness and their equity. System thinking can provide a way
respective determinants. Without this broader forward for operating more successfully and
u n d e r s t a n d i n g o f a s y s t e m ’s c a p a c i t y, effectively in complex, real-world settings. It can
the research and development community open powerful pathways to identifying and
struggles to design specific interventions that resolving health system challenges, and as such
optimize the health system’s ability to deliver is a crucial ingredient for any health system
essential health interventions. And – crucially – strengthening effort.
all too often there is another poorly appreciated
phenomenon: every health intervention, from
the simplest to the most complex, has an effect Key terms and
on the overall system. Presumably simple terminology
interventions targeting one health system entry
Arriving first at a clear set of concepts and
point have multiple and sometimes counter-
terminology is essential, and to that end we
intuitive effects elsewhere in the system. Even
discuss below the key terms used throughout this
when we anticipate the system-wide effects
Report: the health system, health system building
of multi-faceted and complex interventions,
blocks, “people,” systems thinking, system-level
our approaches to charting, evaluating and
interventions, and evaluation.
understanding them are often weak and
sometimes entirely absent. It is increasingly clear The Health System. Following the definition
that no intervention – with a particular emphasis of the World Health Organization, a health
on system-level or system-wide interventions – system “consists of all organizations, people and
ought to be considered “simple”. actions whose primary intent is to promote,
It is imperative that we understand the complex restore or maintain health” (5). Its goals are
effects, synergies 1 and emergent behaviour “improving health and health equity in ways that
of system interventions in order to capitalize are responsive, financially fair, and make the best,
on the current momentum of building stronger or most efficient, use of available resources” (5).
health systems (8). As investments in health In referring to the individual components
are expanded and as funders increasingly of health systems, this Report uses the current
support broader initiatives for health system WHO “Framework for Action” on health systems,
strengthening, we need to know not only which describes six clearly defined Health
How we design what works but for whom, and under what System Building Blocks that together
interventions and
circumstances (9-17). constitute a complete system (5). Throughout
evaluate effects, for
both health systems How we design interventions and evaluate this Report, these building blocks serve as
strengthening a convenient device for exploring the health
effects, for both health systems strengthening
interventions and
for interventions interventions and for interventions targeting
targeting specific specific health diseases or conditions are the
diseases or conditions, challenges at the heart of this Report. We argue
are the challenges 1
A “synergy” is a situation where different entities
at the heart of throughout that a systems thinking approach can combine advantageously – where the whole becomes
this Report. greatly benefit overall health-sector development. greater than the sum of the individual parts.

system and understanding the effects of Health financing: raising adequate funds for
n
interventions upon it. These building blocks are: health in ways that ensure people can use
Service delivery: including effective, safe, and
n needed services, and are protected from
quality personal and non-personal health financial catastrophe or impoverishment
interventions that are provided to those in associated with having to pay for them;
need, when and where needed (including Leadership and governance: ensuring
n
infrastructure), with a minimal waste of strategic policy frameworks combined with
resources; effective oversight, coalition building,
Health workforce: responsive, fair and
n accountability, regulations, incentives and
efficient given available resources and attention to system design.
circumstances, and available in sufficient The building blocks alone do not constitute The building blocks
numbers; a system, any more than a pile of bricks alone do not
constitute a system,
Health information: ensuring the production,
n constitutes a functioning building (Figure 1.1).
any more than a pile
analysis, dissemination and use of reliable It is the multiple relationships and interactions of bricks constitutes
among the blocks – how one affects and a functioning building.
and timely information on health
influences the others, and is in turn affected It is the multiple
determinants, health systems performance relationships and
and health status; by them – that convert these blocks into interactions among
a system (Figure 1.2). As such, a health system the blocks – how one
Medical technologies: including medical
n affects and influences
may be understood through the arrangement
products, vaccines and other technologies of the others, and is
and interaction of its parts, and how they enable
assured quality, safety, efficacy and cost- in turn affected by
the system to achieve the purpose for which them – that convert
effectiveness, and their scientifically sound these blocks into
it was designed (5).
and cost-effective use; a system.
Figure 1.1 The building blocks of the health system: aims and attributes (5)
The WHO Health System Framework

System Building Blocks Overall Goals / Outcomes
SERVICE DELIVERY
HEALTH WORKFORCE IMPROVED HEALTH

ACCESS
(level and equity)
COVERAGE
INFORMATION
RESPONSIVENESS
MEDICAL PRODUCTS,
VACCINES & TECHNOLOGIES SOCIAL & FINANCIAL RISK
PROTECTION
QUALITY
FINANCING SAFETY
IMPROVED EFFICIENCY
LEADERSHIP / GOVERNANCE
The health system Health systems are often seen as monolithic, as People. It is critical that the role of people is
building blocks are a macro system with little attention paid to highlighted, not just at the centre of the system
sub-systems of
the interaction among its component parts, when as mediators and beneficiaries but as actors
the health system
that function – in fact they are a dynamo of interactions, in driving the system itself. This includes their
and therefore must synergies and shifting sub-systems. If we see participation as individuals, civil society
be understood – the building blocks as sub-systems of the health organizations, and stakeholder networks, and
together in
a dynamic system, we see that within every sub-system is a l s o a s ke y a c t o r s i n f l u e n c i n g e a c h o f
architecture of an array of other systems. All systems are the building blocks, as health workers, managers
interactions and contained or “nested” within larger systems and policy-makers. Placing people and their
synergies.
(18;19). Within the heath system is the sub- institutions in the centre of this framework
system for service delivery; within that system emphasizes WHO’s renewed commitment to
may be a hospital system, and within that the principles and values of primary health care –
a laboratory system; and among all of these fairness, social justice, participation and inter-
sub-systems are reactions, synergies and sectoral collaboration (20;21).
interactions to varying degrees with all of
the health system’s other building blocks.
Figure 1.2 The dynamic architecture and interconnectedness of the health system
building blocks

BOX 1.2 FOUR REVOLUTIONS THAT WILL
TRANSFORM HEALTH AND HEALTH
SYSTEMS
There are four revolutions currently underway that will transform health and health systems.
These are the revolutions in: a) life sciences; b) information and communications technology;
c) social justice and equity; and d) systems thinking to transcend complexity.
Source: Frenk J. "Acknowledging the Past, Committing to the Future". Delivered September 5, 2008.
Available at: http://www.hsph.harvard.edu /multimedia/JulioFrenk/FrenkRemarks.pdf
Italics added for emphasis.
Systems thinking is an approach to problem need a systems thinking approach. However,

solving that views "problems" as part of a wider, more complex interventions – e.g. the scaling-up More complex
dynamic system. Systems thinking involves much of antiretroviral therapy – can be expected interventions can
be expected to have
more than a reaction to present outcomes or to have profound effects across the system,
profound effects
events. It demands a deeper understanding of especially in weaker health systems (Figure 1.3) across the system,
the linkages, relationships, interactions and (25;26). They thus require a systems thinking especially in weaker
approach to illuminate the full range of effects health systems
behaviours among the elements that characterize
the entire system. Commonly used in other and potential synergies. This Report refers to
sectors where interventions and systems are these as "interventions with system-wide
complex, systems thinking in the health sector effects”.
shifts the focus to: “System-level interventions” target one or
the nature of relationships among the building
n
multiple system building blocks directly or
blocks generically (e.g. human resources for health),
rather than a health problem specifically. Given
the spaces between the blocks (and under-
n
their effects on other building blocks, “system-
standing what happens there)
level interventions” strongly benefit from
the synergies emerging from interactions
n a systems thinking approach. As explored in
among the blocks. detail in Chapter 3 of this Report, a financing
The application of systems thinking in the health instrument such as paying-for-performance is
sector is accelerating a more realistic under- a “system-level intervention” as it will affect
almost all other building blocks of the health
standing of what works, for whom, and under
system. It will for example present governance
what circumstances (22-24).
challenges around the accountability and
Interventions with system-wide effects transparency concerning bonus payments
and system-level interventions. All health dispensed to staff in health facilities; affect the
interventions have system-level effects to information system in tracking and reconciling
a greater or lesser degree on one or more of the conditions triggering cash payments; strongly
the system’s building blocks. Many may be influence service delivery by changing staff
relatively simple interventions or incremental behaviour, increasing utilization, or possibly
changes to existing interventions – e.g. adding crowding-out other services; might conflict with
vitamin A supplementation to routine vaccination other financing modalities, potentially running
– and not all interventions will benefit from or counter to sector-wide and budget support
approaches; and it may also shape human instructive in terms of the systems strengthening
resources by improving (or eroding) provider necessary to achieve the health goals. Such
motivation. a p p r o a c h e s t o e va l u a t i o n o f t e n i n h i b i t
A systems thinking approach will help to the broader systems perspective and a fuller
anticipate and mitigate such effects understanding of how interventions do or do
when developing interventions, as well as not work, for whom, and under what conditions.
harnessing unexpected synergies by modifying The systems thinking approach goes beyond
the interventions. This then provides the basis this “input-blackbox-output” paradigm to one
for understanding how to measure them that considers inputs, outputs, initial,
in better designed and more comprehensive intermediate and eventual outcomes, and
evaluations. feedback, processes, flows, control and contexts
(22). Given that all evaluations are necessary
Evaluation. The conventional evaluation
simplifications of real-world complexity, systems
of inputs, outcomes and impacts can only take
thinking helps to determine how much – and
us so far, often failing to illuminate the key
where – to simplify. A systems thinking approach
determinants and contexts that explain overall
can connect intervention design and evaluation
success or create particular difficulties. Funders
more explicitly, both to each other and to
and programmes seeking to understand and
the health system framework – though it should
evaluate their investments and inputs tend
be added that not all interventions require
to focus more on downstream disease and
evaluation or evaluation with a systems thinking
mortality impacts. As a result, they often neglect
lens (see Figure 1.3).
the wider health system synergies and emergent
behaviour that might, in the end, be more
Figure 1.3 A spectrum of interventions and their potential for system-wide effects
SCALE-UP ANTIRETROVIRAL THERAPY

INCREASING COMPLEXITY OF INTERVENTION
INTEGRATE VOUCHERS FOR MALARIA

BEDNETS INTO ANTENATAL CARE
SOCIAL
ADD CADRE OF COMMUNITY HEALTH
HEALTH WORKERS INSURANCE
CONDUCT VITAMIN A
SUPPLEMENTATION CAMPAIGN G
IN PAY-FOR-PERFORMANCE
ST I NK
CHANGE 1 LINE TREATMENT TH
FOR MALARIA S
TEM CONDITIONAL CASH TRANSFER
Y S
S
CHANGE R
FO
MICROSCOPY ED
GUIDELINES NE ADD NEW VACCINE TO
G
S IN IMMUNIZATION PROGRAM
EA
NCR
I INCREASE HEALTH
IMPROVE LOCAL USE OF HMIS DATA
WORKER SALARIES
INCREASING SYSTEM-WIDE EFFECTS

BOX 1.3 INDICATORS AND TOOLS
FOR MONITORING CHANGES
IN HEALTH SYSTEMS
Interventions designed to strengthen the system – and their evaluations – often undervalue
the need to understand, strengthen and evaluate the relationships among the system’s
building blocks. Work to develop sensitive and easily measurable indicators for monitoring
changes within each health system building block is ongoing. Such tools are necessary
if systems are to become capable of achieving the effective and universal coverage –
at sufficient quality and safety – necessary for improved health and health equity,
responsiveness, risk protection and efficiency.
For more on these indicators and tools, see WHO 2009 Draft Toolkit for Strengthening Health
Systems. Available at: http://www.who.int/healthinfo/statistics/toolkit_hss/en/index.html
effect approaches. Primarily aimed at intervention

Overview of the Report
designers and evaluators, Chapter 3 introduces
We pursue several goals in this Report. Its the scientific rationale for evaluations that take
primary goal is to catalyze new conceptual a systems perspective and illustrates – in ten
thinking on health systems, system-level steps – how interventions with a system-wide
interventions, and health system strengthening. impact could be better designed and evaluated.
For this we introduce systems thinking and show This includes guidance for developing conceptual
how it might improve intervention design and frameworks and understanding system-wide
evaluation by more careful consideration of implications, and an overview of relevant
system-wide effects. We explore the scientific intervention design and evaluation questions,
foundations for this, providing both a conceptual choice of indicators, and how to match
and an operational approach to designing and evaluation designs to intervention designs.
evaluating interventions with a systems This chapter is further informed by the nature
perspective. This includes illustrating important and gaps in recent evaluations of system-level
on-going challenges and proposing practical interventions (reviewed as a background to this
steps, while also reinforcing advocacy for funding Report, with a summary of findings available in
and conducting evaluations of health systems the Web Annex at http://www.who.int/alliance-
strengthening interventions. hpsr/resources/en/ ).
In Chapter 2, we introduce and explore systems Of course, applying a systems thinking per-
thinking and what it means for the health system spective is far from straightforward, marked by
as an overall primer to the issues and relevant as many challenges as opportunities. It can, for
literature. The chapter is targeted to all audiences instance, enhance a more inclusive participatory
(including system stewards, intervention approach that fosters direct links to policy-
designers, researchers, evaluators, and funding making, and better ownership of processes and
partners). outcomes. It can build national capacity in
While retaining a rigorous scientific base, systems solving health system problems and facilitate use
thinking requires us to go beyond cause-and- of research evidence to inform policy-making.
But it can also run counter to dominant
paradigms and relationships. The complex
dynamics among the public, researchers,
programme implementers, funders and political
agents pose many challenges to the systems
p e r s p e c t i v e. We e x p l o r e s o m e o f t h e s e
implications and provide examples of how they
have been experienced or managed in Chapter 4.
This Chapter mainly targets system stewards,
evaluators, and funding partners.
Finally, Chapter 5 reflects on the way forward
for systems thinking for health systems
strengthening and provides a set of ideas for
various stakeholders.
As with all system-oriented problems, the issues
and approaches discussed here are inherently
intricate and not always intuitive. Our Report
attempts to make the case for a broader systems
thinking approach in an easily accessible form
for a broad interdisciplinary audience, including
h e a l t h s y s t e m s t e wa r d s, p r o g ra m m e
implementers, researchers, evaluators and
funding partners. It is hoped that this Report will
stimulate and legitimize more carefully
considered funding for better interventions for
health systems strengthening and their
evaluation as well as fresh thinking, broader
approaches, and research that respects and
informs the systems approach.

2
Systems thinking:
What it is and what it means
for health systems
Key messages
Using a systems perspective to understand how health system

n
building blocks, contexts, and actors act, react and interact
with each other is an essential approach in designing and
evaluating interventions.
Mainstreaming a stronger systems perspective in the health

n
sector will assist this understanding and accelerate health
system strengthening.
Systems thinking offers a comprehensive way of anticipating

n
synergies and mitigating negative emergent behaviours, with
direct relevance for creating policies that are more system-
ready.
“The responses of many health systems so far have been generally considered
inadequate and naïve. Inadequate, insofar as they not only fail to anticipate,
but also to respond appropriately – too often with too little, too late,
or too much in the wrong place. Naïve insofar as a system’s failure requires
a system’s solution – not a temporary remedy.“
WHO World Health Report, 2008.
Objectives of the Chapter Systems thinking

th
Systems thinking is an essential approach for Systems thinking has its origins in the early 20
strengthening health systems, particularly in century in fields as diverse as engineering,
designing and evaluating interventions. Chapter economics and ecology. With the increasing
1 described the current WHO framework for emergence of complexity, these and other non-
action in strengthening health systems, a single health disciplines developed systems thinking
people-centered framework combining six clearly to understand and appreciate the relationships
defined building blocks or sub-systems (5). within any given system, and in designing and
However, despite the rising prominence (and evaluating system-level interventions (18;27-33).
sometimes rhetoric) of health systems In recent years, the health sector has started
strengthening among governments and funders, to adopt systems thinking to tackle complex
there is little guidance on how to do so. Many sectoral problems such as tobacco control (22),
subsequent programmes and evaluations still obesity (34-36), and tuberculosis (37). However,
ignore the fundamental characteristics of few have tried to implement these concepts
systems, often considering the individual building beyond single issues to the health system
blocks in isolation rather than as part of itself, or described how to move from theory to
a dynamic whole. Conceptualizing the synergies, practice (18;27) – perhaps due to the seemingly
intended or not, of intervening in the health overwhelming complexity of any given health
system depends upon a fuller understanding of system (29;38-40).
the “system,” and how its component parts act, More recently, the suggestion of applying
react and interact with each other in an often systems thinking to the health system
counter-intuitive process of connectivity and has emerged (41), assisted in some ways by
change. As a primer to the issues and relevant the WHO’s 2007 articulation of the health system
literature, this chapter discusses system building blocks (see Chapter 1 for an intro-
characteristics and the paradigm shift of systems duction to this). Although that framework may
thinking for strengthening health systems. be challenged as tilted towards supply-side
inputs, it does provide a valuable device for
conceptualizing the health system and
appreciating the utility of systems thinking.
CHAPTER 2 WHAT IT IS AND WHAT IT MEANS FOR HEALTH SYSTEMS 39

BOX 2.1 COMMON SYSTEMS CHARACTERISTICS
Most systems, including health systems, are:

n
Self-organizing n
Non-linear
n
Constantly changing n
History dependent
n
Tightly linked n
Counter-intuitive
n
Governed by feedback n
Resistant to change
Compiled and adapted from Sterman, 2006 and Meadows et al, 1982 (32;42)
systems (Box 2.2). The building block framework

Bringing the system into
shows how the nature, dynamics and behaviour
focus with a systems of health systems is shaped by the multiple
thinking lens and complex interactions among the blocks –
and not by the behaviour of any one block alone.
Understanding the fundamental characteristics of
For example, weak stewardship structures
systems is crucial to seeing how systems work.2
(the leadership and governance building
The characteristics described in Box 2.1 influence
block) often disregard or ignore valuable
– especially when taken together – how systems,
communication and feedback (the health
including health systems, respond to external
information building block), leading to policies
factors or to an intervention.
and practices that do not adequately respond
S e l f - o rg a n i z i n g – s y s t e m d y n a m i c s to the latest information or evidence. The internal
arise spontaneously from internal structure. structure and organization – marked in this case
No individual agent or element determines by a weak or malfunctioning link between
the nature of the system – the organization the governance and information blocks –
of a system arises through the dynamic influences to a great degree the functions and
interaction among the system’s agents, abilities of the system itself.
and through the system’s interaction with other
BOX 2.2 SYSTEM BEHAVIOUR
“A system to a large extent causes its own behaviour. Once we see the relationship between
structure and behaviour, we can begin to understand how systems work, what makes them
produce poor results, and how to shift them into better behaviour patterns. System structure
is the source of system behaviour. System behaviour reveals itself as a series of events
over time” (43).
2
Our definition of “system” is described in the literature
as a “complex adaptive system” – one that self-organizes,
adapts and evolves with time. “Complexity” arises
from a system’s interconnected parts, and “adaptivity”
from its ability to communicate and change based
on experience (22;38).

Constantly changing – systems adjust and may otherwise not choose to use if they had
readjust at many interactive time scales. Change to pay for them. Anticipating these positive Anticipating positive
is a constant in all sustainable systems. Indeed, and negative effects within a context of inter- and negative effects
within a context
systems that do not change ultimately collapse connection is key to designing and evaluating of interconnection
since they are part of wider systems that do. As an intervention over time. Without a systematic is key to designing
systems are adaptive rather than static, they have framework to consider possible major synergies and evaluating
an intervention
the ability to generate their own behaviour; (or negative emergent behaviour), the less over time.
to react differently to the same inputs in obvious effects of an intervention may
unpredictable ways; and to evolve in varying be missed, either at the design or evaluation
ways through interconnections with other parts phase (44).
of the system (which in turn are constantly
Governed by feedback – a positive or
changing). This element of change and negative response that may alter the intervention
adaptation poses particular and often hidden or expected effects. Systems are controlled by
challenges in evaluating or understanding “feedback loops” that provide information flows
discrete health systems interventions. Given on the state of the system, moderating behaviour
those constant interactions and the impossibility as elements react and “back-react” on each
of freezing individual dynamics, interventions and other. One such example is the change of
their effects can hardly be fully understood provider practice patterns (44). This adaptation
or effectively measured in isolation from other and change of behaviour among providers
system building blocks. For example, in a hospital requires monitoring, evaluating and the design
(a sub-system of the service delivery block), of new mechanisms (within the information
reducing the length of stay in one ward may block, for instance) to counteract potential
result in increased re-admission rates in another negative effects over time.
part, compromising quality and costs (41).
Non-linearity – relationships within a system
Tightly-linked – t h e h i g h d e g r e e o f cannot be arranged along a simple input-output
connectivity means that change in one line. System-level interventions are typically non-
sub-system affects the others. Related to linear and unpredictable, with their effects often
the characteristic of change and adaptation is disproportional or distantly related to the original
the notion that any intervention targeting one actions and intentions. For instance, interventions
building block will have certain effects (positive to increase quality of care are likely to succeed
and negative) on other building blocks. For initially, but as skills reach a certain level or
instance, introducing a universal health insurance caseloads increase beyond what health workers
scheme to protect households from high or will accept, the quality-enhancing effects of
unexpected health expenditures may lead to the intervention may flatten or actually decrease
the increased utilization of services that patients over time (45).

History dependent – short-term effects within a system have their own, and often
of intervening may differ from long-term effects. competing, goals (43). For example, a conditional
Time delays are under-appreciated forces cash transfer designed to change or increase
affecting systems. For example, community health health-seeking behaviour may in fact worsen
insurance schemes intending to generate the existing situation through the rise of
resources to improve the quality of primary unintended behaviours (e.g. mothers keeping
health services may fail to generate sufficient children malnourished to maintain eligibility).
initial resources to drive quality change. This
could lead to dissatisfaction and the potential BOX 2.3 THE
collapse of the intervention before coverage CONNECTIONS
can reach the critical thresholds to actually AND
Interventions improve services (46). Interventions designed CONSEQUENCES
designed to change to change people's behaviour require measuring OF SYSTEMS
people's behaviour THINKING
require measuring the intervention effects over a longer period
the intervention of time to avoid making incorrect conclusions
effects over a longer Systems thinking places high value
of no or limited effects.
period of time to on understanding context and looking
avoid making Counter-intuitive – cause and effect are for connections between the parts, actors
incorrect conclusions often distant in time and space, defying solutions
of no or limited and processes of the system (Lucy Gilson,
that pit causes close to the effects they seek
effects. personal communication) (48). They
to address. Some apparently simple and effective
make deliberate attempts to anticipate,
interventions may not work in some settings –
rather than react to, the downstream
while functioning perfectly well in others. For
consequences of changes in the system,
example, providing a conditional cash transfer
and to identify upstream points
to communities to encourage them to seek care
of leverage (David Peters, personal
may only work effectively in settings where
communication) (35;49-51). None of
transport and access to those services is
this is unfamiliar to those working
affordable, but not elsewhere. Furthermore, such
in health systems, but what is different
an intervention may dramatically increase
in systems thinking the deliberate,
utilization with the risk of overwhelming services
continuous and comprehensive way
that were not strengthened in parallel.
in which the approach is applied (22).
Systems thinking Resistant to change – seemingly obvious
offers a more solutions may fail or worsen the situation.
comprehensive way
Given the above characteristics of systems, and
of anticipating
synergies and the complexity of their many interactions, it is
mitigating negative sometimes difficult and delicate to develop
emergent behaviours, a priori an effective policy without a highly
with direct relevance
for creating more astute understanding of the system. System
system-ready policies. characteristics can render the system “policy
resistant,” particularly when all of the actors

and evaluation of programmes and investments
Systems thinking –
(47). We need a radical shift in the intervention
a paradigm shift design and evaluation approaches for health
Given these complex relationships and systems (37;48), along with anaccompanying
characteristics of the health system, applying shift in mindset among designers, implementers,
conventional approaches commonly used to stewards and funders.
design and evaluate interventions will not The type of skills needed for system thinking –
take us far enough. These approaches are and the required shift in the way of thinking –
usually described in linear input-output-outcome- are illustrated in Table 2. 1, comparing the more
impact chains which drive the log-frames usual with the systems thinking approach.
characteristically underpinning the monitoring
Table 2.1 Skills of systems thinking
Usual approach Systems thinking approach
Static thinking Dynamic thinking
Focusing on particular events Framing a problem in terms of a pattern

of behaviour over time
Systems-as-effect thinking System-as-cause thinking
Viewing behaviour generated by a system Placing responsibility for a behaviour on

as driven by external forces internal actors who manage the policies
and "plumbing" of the system
Tree-by-tree thinking Forest thinking
Believing that really knowing something Believing that to know something requires
means focusing on the details understanding the context of relationships
Factors thinking Operational thinking
Listing factors that influence or correlate Concentrating on causality and under-

with some result standing how a behaviour is generated
Straight-line thinking Loop thinking
Viewing causality as running in one Viewing causality as an on-going process,

direction, ignoring (either deliberately or not a one-time event, with effect feeding
not) the interdependence and interaction back to influence the causes and the causes
between and among the causes affecting each other
Modified from Richmond, 2000 (28).

System stakeholder
networks
Another vital aspect of systems thinking revolves Different stakeholders may each see the purpose
around how system stakeholder networks are of the system differently (as in Box 2.4), a series
included, composed and managed, and how of perspectives that can offer new insights into
context shapes this stakeholder behaviour. how the health system works, why it has problems,
Stakeholders are not only at the centre of how it can be improved, and how changes made to
the system as mediators and beneficiaries but are one component of the system influence the other
also actors driving the system itself. This includes components (52).
their participation as individuals, civil society
organizations, and stakeholder networks, and
also as key actors influencing each of the building
blocks, as health workers, managers and policy-
makers.
BOX 2.4 SYSTEM STAKEHOLDER NETWORKS
The concept of “multi-finality” shows how stakeholder perspectives on the health

system could vary. A health system could be considered:
n
a “profit making system“ from the perspective of private providers
n
a “distribution system“ from the perspective of the pharmaceutical industry
n
an “employment system“ from the perspective of health workers
n
a “market system” from the perspective of household consumers and providers of health-
related goods and services
n
a “health resource system“ from the perspective of clients
n
a “social support system“ from the perspective of local community
n
a “complex system” from the perspective of researchers / evaluators
n
a set of “policy systems” from the perspective of government
n
a set of “sub-systems” from the perspective of the Ministry of Health
Health systems may also be considered by some development aid donors as a “black box”
with unacceptably low predictability or a “black hole” where funding goes in,
but little comes out.
Modified from Wikipedia: Systems thinking (http://en.wikipedia.org/wiki/Systems_thinking). Accessed

October 12, 2009.

BOX 2.5 SYSTEMS THINKING ELEMENTS
Systems Managing and leading a system; the types of rules that govern the system
organizing and set direction through vision and leadership, set prohibitions through
regulations and boundary setting, and provide permissions through setting
incentives or providing resources
Systems Understanding and managing system stakeholders; the web of all

networks stakeholders and actors, individual and institutional, in the system, through
understanding, including, and managing the networks
Systems Conceptually modeling and understanding dynamic change; attempting

dynamics to conceptualize, model and understand dynamic change through
analyzing organizational structure and how that influences behaviour
of the system
Systems Managing content and infrastructure for explicit and tacit knowledge;
knowledge the critical role of information flows in driving the system towards
change, and using the feedback chains of data, information and evidence
for guiding decisions
Modified from Best et al, 2007 (22).
Another view
of interventions
Health interventions may be aimed at individuals are thus inherently more complex to design Systems thinking
(through clinical or technical interventions and evaluate appropriately. Systems thinking sees a complex
intervention as
such as new drugs, vaccines and diagnostics) looks at a complex intervention as a system a system in itself,
or at populations (through public health in itself, interacting with other building blocks interacting with
interventions such as health education of the system and setting off reactions that other building blocks
of the system and
or legislative efforts). These interventions may well be unexpected or unpredictable.
setting off reactions
often have implications for health systems that A p a r t f r o m a s m a l l n u m b e r o f s t u d i e s, that may
are more complicated than first appreciated. the interaction between health systems be unexpected or
When interventions primarily aim to change or and health interventions is not well understood unpredicted –
in the absence of
strengthen the health system itself, the issue or explored (37). Table 2.2 illustrates some a systems thinking
becomes even more complicated with regard typical system-level interventions. approach
to how the system responds. Such interventions

Table 2.2 Typical system-level interventions targeting individual or multiple
building blocks
Building block Common types of interventions
Governance - Decentralization
- Civil society participation
- Licensure, accreditation, registration
Financing - User fees

- Conditional cash transfers (demand side)
- Pay-for-performance (supply side)
- Health insurance
- Provider financing modalities
- Sector Wide Approaches (SWAps) and basket funding
Human Resources - Integrated Training

- Quality improvement, performance management
- Incentives for retention or remote area deployment
Information - Shifting to electronic (versus manual) medical records

- Integrated data systems & enterprise architecture for HIS design
- Coordination of national household surveys (e.g. timing of data
collected)
Medical products, - New approaches to pharmacovigilance

vaccines and - Supply chain management
technologies - Integrated delivery of products and interventions
Service delivery - Approaches to ensure continuity of care

- Integration of services versus centrally managed programmes
- Community outreach versus fixed clinics
Multiple building - Health sector reforms

blocks - District health system strengthening

Intervening at high Implications of systems
leverage points thinking for designing
in the system and evaluating health
A health system, as with any adaptive system, interventions
is vulnerable to certain leverage or “tipping” In this chapter we have introduced systems
points at which an apparently small intervention thinking in broad concepts and how this relates
can result in substantial system-wide change to health systems. We have shown how systems
(53). For instance, a seemingly minor event thinking takes account of patterns of interaction
(e.g. freezing health worker salaries) may tip and patterns of change. Considering and
the system into large-scale change or crisis appreciating the intricacies of the health system
(e.g. provoking a health worker strike). On does not mean adding undue complexity to what
the positive side, such interactions could also appears a simple intervention designed to
be managed in a way that leads to synergies. achieve one outcome. However, it does mean
However, it is often difficult to identify such that in designing and evaluating system-level
leverage points, and there is no easy formula interventions or interventions with system-wide
for finding them. While systems analysis can be effects, a comprehensive assessment of the main
instructive as to where such leverage points may effects (intended or not) and the contextual
be found, more often than not interventions are factors that may help explain the success or
selected based on intuition and the prevailing failure of the intervention are essential. This is
d e v e l o p m e n t p a ra d i g m s. A s u m m a r y o f also instrumental in foreseeing and monitoring
interventions in other (non-health) systems (53), consequences, especially negative or unintended,
suggests that high leverage points are and designing mechanisms to measure and
located in two sub-systems – governance and address them (54). Multi-disciplinary and multi-
information. These are two of the health stakeholder involvement is central to this process
system’s building blocks, and the two that and cannot be over-emphasized, especially
receive the least attention from health system for health systems research (19).
interventionists (24). Missing information
Chapter 3 shows how to develop and evaluate
flows are often identified as the most common
a health system intervention from a systems
cause of system malfunction (43), and incapable
thinking perspective by using an example
or overstretched governance structures can
to illustrate the full range of ramifications and
contribute to less than optimal performance and
steps in its practical application.
cohesion among the building blocks and for
the system as a whole.

3
Systems thinking: Applying
a systems perspective
to design and evaluate
health systems interventions
Key messages
The design and eventual evaluation of any health system

n
intervention must consider its possible effects across all major
sub-systems of the health system.
A collective systems thinking exercise among an inclusive set

n
of health system stakeholders is critical to designing more
robust interventions and their evaluations.
A conceptual pathway of dynamic sub-system interactions

n
can help forecast how the intervention will trigger reactions
in the system, and how the system itself will respond.
Following collective brainstorming and mapping conceptual

n
pathways, interventions may be re-designed to bundle
in additional elements amplifying previously unappreciated
synergies and mitigating potentially negative effects.
Probability designs (randomized controlled trials) of

n
large-scale health system interventions are often considered
the best designs with high internal validity to evaluate
efficacy, but are not always feasible or acceptable; when
the are, they are rarely sufficient without complementary
contextual and economic evaluations.
Plausibility designs and other designs that use mixed methods

n
to provide estimates of adequacy, processes, contexts, effects
and economic analyses are often the more appropriate design
for evaluations of interventions with system-wide effects.
"A systems perspective can minimize the mess; many
of today's problems are because of yesterday's solutions"
Dr. Irene Akua Agyepong, Ghana Health Service
Ministry of Health, Ghana, 2009
Introduction Systems thinking:

WHO has provided a single people-centered A case illustration
framework combining six clearly defined building Performance-based funding (PBF) has emerged Anticipating
blocks or sub-systems that, taken together, in recent years as a popular paradigm both relationships and
comprise a complete health system (20;21). reactions among
in developed countries and for development the sub-systems
As argued in Chapter 2, understanding
assistance. In the health sector, two specific and the various actors
the relationships and dynamics among these in the system is
instruments of performance-based funding are
sub-systems is crucial in the design and evaluation essential in predicting
attracting attention of countries and donors possible system-wide
of system-level interventions and interventions
seeking to boost performance in health systems. implications and
with system-wide effects. We must consider both effects.
These are paying-for-performance (P4P) and
the intervention and the system as complex and
conditional cash transfers (CCTs) (59-63). Paying-
dynamic when designing the intervention and
for-performance is usually implemented as
its evaluation (17;26;55-58).
a supply-side cash incentive given to health care
This Chapter builds on the definitions and providers on achievement of a pre-specified
concepts introduced in Chapters 1 and 2, performance target. Conditional cash transfers
and uses the case of a major contemporary are a demand-side cash incentive given to clients
system-level intervention to demonstrate both of the health system to encourage them to adopt
the systems thinking and the more conventional particular health behaviours or utilize a specified
approaches. The “Ten Steps to Systems Thinking”
health service. They are both system-level
developed here is intended to provide guidance
interventions that target multiple building blocks
on applying the systems perspective for a broad
(service delivery and financing), with potentially
audience of designers, implementers, stewards,
powerful effects on other sub-systems.
evaluators and funders. For any intervention with
system-wide effects, we ask: As these major system-level interventions are
extended to a national scale, health system
how can we anticipate potential effects?
n
stakeholders need to know whether they work,
how can we conceptualize the actual
n
for whom they work, and under what particular
behaviour of the intervention? and
conditions and contexts. All too often they must
how can we redesign a more sophisticated
n do this without the benefit of small-scale pilot
intervention that accounts for those potential studies, as these may be politically difficult or
effects? operationally meaningless. For a P4P intervention
Answering these questions leads into wider issues that puts a cash bonus in the pockets of health
of evaluation, and underlines the importance workers, stakeholders will need to know if
of designing, funding and implementing the intervention is good value for money –
an evaluation before the intervention is rolled money that might otherwise be invested directly
out in order to capture baselines, comparators and in improving health services or other aspects
the full range of effects over time. of the system.
CHAPTER 3 APPLYING A SYSTEMS PERSPECTIVE TO DESIGN AND EVALUATE HEALTH SYSTEMS INTERVENTIONS 51
BOX 3.1 A PAY-FOR-PERFORMANCE
INTERVENTION -
1
AN ILLUSTRATIVE EXAMPLE
In a low-income country, the Ministry of Health, Ministry of Finance and their international
funding partners decide to launch a Pay-for-Performance (P4P) programme to improve
service quality. After internal discussion, they determine that tuberculosis care and
treatment is unacceptably weak, and that a P4P programme could be used to increase
the effective coverage of Tuberculosis Directly Observed Short Course Treatment (TB DOTS).
The P4P intervention specifies that cash awards will be paid to TB DOTS health care
providers every six months upon successful achievement of targets for increased coverage
(utilization and adherence) rates. Every health facility in the country negotiates their
own effective coverage targets, and the country’s health information system (HIS) will be
used to monitor the targets.
The Problem: low rates of TB patient uptake and adherence to TB DOTS in detected cases.
The Policy Response: introduction of financial incentives for TB DOTS providers who
succeed in increasing uptake and adherence rates.
Anticipated Outputs: incremental improvements in uptake and adherence rates.
Results: adherence rates increase by x%. Costs of the incentive package increase by y%.
Anticipated Outcomes: higher effectiveness of TB DOTS in reducing morbidity, mortality
and risk of TB.
Following two years of implementation, the official evaluation of the programme focused on
costs to the health system and TB DOTS adherence rates. It concluded that the programme was
a success. However, though not part of the official evaluation, some field-based staff reported
fundamental problems with the programme. They observed that health facility staff were
moving towards the more “lucrative” TB services at the expense of other core services,
compromising the quality of services each facility offered. Some reported widespread gaming
and even outright corruption, which the weak HIS was unable to capture.
While these issues may have remained an unavoidable but manageable consequence
of improved TB services, a sudden measles epidemic brought all of these problems into new
light. With fewer capable staff at most health facilities, the system was less able to manage
cases or prevent the epidemic from spreading. Many observers increasingly felt that
the benefits of the TB programme were more than offset by the increased costs, morbidity
and mortality elsewhere in the health system.
Could these problems have been identified and mitigated at the design stage
of the intervention?
1
This case illustration is a hypothetical example composed
of experiences from a number of real cases.

The more conventional approach service delivery to improve patient uptake and In the more
t o t h e i n t e r v e n t i o n . A s a p a y - f o r- adherence. This will likely manifest itself in local conventional
approach, interest
performance instrument, the goal of a P4P low- or no-cost innovations in attracting patients
is centered on
is to achieve an impact on a specific issue. to diagnosis, and maintaining them on treatment. the linear process,
In essence, the P4P “purchases” and supports The assumption here is that improved quality output, outcome
a narrow component of health care delivery. translates to more effective coverage, which and eventual impact
of the intervention.
Without a systems perspective, interest tends in turn results in better health in the population,
to centre on this narrow component, and and better equity and responsiveness of
the linear process, output, outcome and the health system itself.
eventual impact of the investment. Notably,
Revisiting the intervention from
the intervention funder itself typically contracts a systems perspective. Since the P4P is
the evaluation of the P4P and the target a major, high-cost, system-level intervention
disease programme, and sets the parameters operating through a new financing mechanism,
they want evaluated. The resultant evaluation it demands a systems perspective (29;33;64),
In moving beyond
only illuminates the most obvious direct, linear including fuller use of system leadership and the “input-blackbox-
inputs and expected effects of the intervention broader networks (stakeholders), systems output” paradigm,
in terms of costs, coverage, uptake and equity organization, and systems knowledge (see the systems
of the intervention in question. perspective considers
Chapter 2 for a discussion of these concepts) inputs, outputs,
Figure 3.1 illustrates the more conventional (22). In moving beyond the “input-blackbox- initial, intermediate
approach. The P4P intervention targets service output” paradigm, the systems perspective and eventual
delivery through increased financing, and outcomes, and
considers inputs, outputs, initial, intermediate and
feedback, processes,
operates on the assumption that health workers eventual outcomes, and feedback, processes, flows, control
will change something in the quality of TB DOTs flows, control and contexts (22). and contexts.
Figure 3.1 More conventional pathway from P4P financing intervention

to expected effects
Health system building blocks Overall goals /

Outcomes
LEADERSHIP/
GOVERNANCE
P
SERVICE DELIVERY
COVERAGE E IMPROVED
HEALTH
(level and equity)
UTILIZATION O
HUMAN RESOURCES
QUALITY
P
INFORMATION
L
FINANCING
E
MEDICAL PRODUCTS,
VACCINES AND
perception RESPONSIVENESS
TECHNOLOGIES of services
Ten Steps to Systems
Thinking
As a guide to applying this perspective, less an exact and rigid blueprint and more
we propose “Ten Steps to Systems Thinking,” a conceptualized process. They are flexible
and use our case illustration to show how and may be adapted to many different situations
they might work in practice. These steps are and possibilities.
BOX 3.2 TEN STEPS TO SYSTEMS THINKING:

APPLYING A SYSTEMS PERSPECTIVE
IN THE DESIGN AND EVALUATION
OF INTERVENTIONS
I: Intervention Design
1. Convene stakeholders: Identify and convene stakeholders representing each
building block, plus selected intervention designers and implementers, users of the
health system, and representatives of the research community
2. Collectively brainstorm: Collectively deliberate on possible system-wide
effects of the proposed intervention respecting systems characteristics (feedback, time
delays, policy resistance, etc.) and systems dynamics
3. Conceptualize effects: Develop a conceptual pathway mapping how the
intervention will affect health and the health system through its sub-systems
4. Adapt and redesign: Adapt and redesign the proposed intervention to optimize
synergies and other positive effects while avoiding or minimizing any potentially
major negative effects.
II: Evaluation Design

5. Determine indicators: Decide on indicators that are important to track in
the re-designed intervention (from process to issues to context) across the affected
sub-systems
6. Choose methods: Decide on evaluation methods to best track the indicators
7. Select design: Opt for the evaluation design that best manages the methods
and fits the nature of the intervention
8. Develop plan and timeline: Collectively develop an evaluation plan
and timeline by engaging the necessary disciplines
9. Set a budget: Determine the budget and scale by considering implications
for both the intervention and the evaluation partnership
10. Source funding: Assemble funding to support the evaluation before
the intervention begins.

Part I: The Intervention
Design
Step 1. Convene stakeholders: Multi- Step 2. Collectively brainstorm: This step
disciplinary and multi-stakeholder involvement is critical in identifying all possible system-wide
is a crucial element throughout the “Ten Steps effects of the proposed intervention. Once
to Systems Thinking” – identifying and convening the right mix of stakeholders has convened
key stakeholders concerned with or affected to discuss the proposed intervention, they
by the intervention’s implementation is essential. anticipate and hypothesize all possible
To legitimate the convening process, this should ramifications of the intervention within each
either start with or be endorsed at a high building block, while also thinking through
official level in the Ministry of Health. There are the many interactions among the sub-systems.
a number of approaches for identifying Front-line implementers (possibly those
stakeholders (including context mapping and representing the service delivery and health
stakeholder analysis) (65;66), however common workforce building blocks) will identify potential
sense should prevail and err on the side effects of the implementation pathway. The final
of inclusivity. At a minimum, at least one aspect of this step will be nominating leaders
knowledgeable representative of each and a smaller design team to take ownership of
sub-system (or building block) is required, plus the intervention, particularly in conceptualizing
at least one representative of the research its effects, redesigning it, and identifying
community and one from a funding partner. individuals to develop its evaluation.
Not all interventions will need all of
the stakeholders described here, however
a complex intervention will require increasing
levels of consultation.
BOX 3.3 THE P4P INTERVENTION –

CONVENING STAKEHOLDERS
Following official decisions to proceed with the intervention, the Ministry of Health’s TB Control
Programme Manager requests the Ministry’s Chief Medical Officer to convene other concerned
directors in the MoH to discuss the opportunity and to identify further stakeholders. This group
(representing governance, financing, human resources, information, essential drugs, and service
delivery) identifies a range of other stakeholders drawn from representatives of the research
community, civil society, the civil service commission, front-line TB DOTs health workers, District
Health Management Teams and the funding partner. Following this identification, the Chief
Medical Officer organizes a schedule of small, short stakeholder consultations and issues
invitations, with the MoH Director of Planning and Policy appointed to facilitate the meetings.
BOX 3.4 THE P4P INTERVENTION –
BRAINSTORMING
Under the facilitation of the Director of Policy and Planning, initial stakeholder workshops
reveal that the principal potential effects of the P4P intervention on the service delivery
sub-system may include the improved attractiveness of services due to better access
and opening hours, and a more welcoming demeanor and behaviour from health workers.
These positive effects should result in increased utilization and hence coverage. However,
potentially negative effects may arise if health workers neglect services that are not rewarded
by the P4P (crowding out). High-performing health workers may already be more available
in advantaged areas than in poorer areas and bonuses may concentrate in their hands, further
increasing existing inequities among the served populations. On the other hand, equity might
be improved if the P4P attracts workers to disadvantaged areas where the opportunities
to improve coverage are perceived as higher, and thus bonuses easier to gain.
The intervention may improve the information sub-system to monitor coverage as a key
means of assessing whether a bonus should be paid or not. However, given existing
weaknesses in the health information system, actors may manipulate it to over-report
improvements to receive bonuses without conditional levels actually achieved. The
information system may not be capable of providing sufficiently sensitive estimates of the
conditional indicator (in this case effective coverage of TB DOTs), and may need direct
strengthening to support the P4P.
Potential positive effects on the human resources sub-system might be improved provider
motivation, including a willingness to work in remote areas. Conversely, intrinsic motivation
might be eroded to the point where workers focus exclusively on tasks where additional
bonuses can be most easily acquired. Staff conflicts and rivalry may arise among the team
and supervisors if only some members qualify for the bonus and if it is unclear how targets
for payment are set and monitored. Additionally, there may be trade union or civil service
impediments to this sort of employee compensation.
The role of those supply- and demand-side effects depends on a variety of governance
factors that may change over time, including increased trust and more effective
decentralization and ownership. Challenges in meeting public accountability and transparency
for the bonus payments may arise. New modalities for handling discretionary cash payments
for staff in health facilities may be needed.
Finally, for the financing sub-system, there might be incrementally more funding, but also an
increased fragmentation of funding modalities – potentially running counter to sector-wide
and budget support principles. The management of cash payments to health facilities has both
financing and governance implications.
Based on the outcomes of this brainstorming process, the stakeholders then prioritize potential
effects according to their importance and likelihood in a tabular format (see Table 3.1)
as a basis for a conceptual framework (see Figure 3.2).

Table 3.1 Prioritized potential system-wide effects of the P4P intervention
Priority Effect Positive + Likelihood Importance Sub-system

1=high or (high, medium, (high, medium,
5=low Negative – low) low)
1 Staff conflicts if bonus not – High High HR

universal
1 Over-reported improvements – High High Information
1 Local incentives to seek solutions + High High Service delivery

to delivery issues
2 Resource allocation imbalance – High Medium Financing

(fragmented funding modalities)
2 Difficulties managing cash – High Medium Financing

payments
2 Increased utilization of TB DOTS + Medium High Service delivery
2 Crowding out of non-target – Medium High Service delivery

health services
2 Frustrated demand for better – Medium High Service delivery

service infrastructure
2 Frustration among public, health – Medium High Medicines &

workers of increased demand without Technoligies
increased technical quality/quantity
3 Reduced accountability and trans- – Medium Medium Governance

parency regarding bonus payments
4 Increased production, use of + Low Medium Information

information/feedback
5 Decentralization (local ownership + Low Low Governance

and control)
5 Reveal and resolve phantom + Low Low Governance

worker issues
5 Increased health worker motivation + Low Low HR
5 Health worker willingness to + Low Low HR

accept postings to remote/
disadvantaged areas
5 Deflection of qualified staff to the – Low Low HR

level where bonus is achievable
Note: this table and Table 3.2 were created at an actual role-playing simulation brainstorming session.
Step 3. Conceptualize effects: In Step 4. Adapt and redesign: In this final
anticipating possible positive and negative effects design step, the initial concept for the inter-
in the other health sub-systems, it is clear that vention will likely need to be adapted or
any major intervention could have important re-designed in light of the first three steps to
unknowns. In this step, a smaller design team optimize synergies and other positive effects
takes the tabular output and develops a concep- while avoiding or minimizing any potentially
tual pathway mapping how the intervention will major negative effects. Based on the expected
affect health and the health system through or hypothesized causal pathway of dynamic
its sub-systems, with particular attention interactions from Step 3 and the table of
A conceptual to feedback loops. This conceptual pathway of potential effects brainstormed in Step 2,
pathway of dynamic dynamic interactions shows how the intervention the stakeholders may re-think their intervention
interactions shows
how the intervention will trigger reactions in the system, and how design to bundle in additional design elements to
will trigger reactions the system might respond (38;67). This highlights mitigate important negative effects, maximize
in the system, and key potential negative and positive effects at all previously unappreciated potential synergies or
how the system
major sub-systems in the health systems avoid any possible obstacles. This is a collective
might respond
framework. While this is an initial pathway, exercise in prioritizing the negative effects into
evaluation designs will need to consider that t h o s e t h a t a r e p o t e n t i a l l y s e r i o u s, a n d
interventions will play out differently in different determining whether and how to amplify
settings with different actors. Concept mapping the positive effects. The group’s response to these
(68) and systems dynamic modeling (33) are effects will contribute directly to ideas for
possible tools to use at this stage (see Chapter 4 the adaptation or redesign of the intervention.
for a discussion of concept mapping).
Figure 3.2 Conceptual pathway for the P4P intervention using a systems perspective
Health system building blocks Overall goals /

Outcomes
/ Accountability
LEADERSHIP/
Trust
GOVERNANCE Decentralization
P
ACCESS
SERVICE DELIVERY
/ COVERAGE E / HEALTH
(level and equity)
/ Improve/over report
HUMAN RESOURCES / UTILIZATION O
/ Motivation Availability
of supplies P
INFORMATION
Retention
rural areas
L
FINANCING
/ EFFICIENCY
& COST
E EFFECTIVENESS
MEDICAL PRODUCTS, /Case
VACCINES AND management
TECHNOLOGIES / QUALITY /
/ Perception
of services RESPONSIVENESS

BOX 3.5 THE P4P INTERVENTION – REDESIGN
In the P4P example, the design team advocates for additional complementary funding
to strengthen the health information system to improve the statistics used to trigger the pay-
for-performance bonus. They restructure how bonuses are awarded across all staff of the facility,
and the district or regional authorities who support those facilities. They also decide to bundle
or raise additional support to handle the anticipated increased demand for health services, and
spread the P4P over a broader spectrum of essential services to avoid crowding out. Lastly,
they recommend opening bank accounts for health facilities to manage timely disbursement
of bonuses.
While led by the design team that conceptualized Once the intervention design has been finalized,
the effects in Step 3, the product created in Step 4 the stakeholders need to decide how it should be
– the adapted design for the intervention – will expanded nation-wide, and begin to consider
ideally be returned to the larger stakeholder the evaluation design. Below, in Part II of
group. This group may elect to convene again, and this Chapter, we consider each of the steps in
may engage in further brainstorming to consider the evaluation design. The discussion is targeted
and weigh the innovations added at this stage. in particular at researchers and evaluators.
Figure 3.3 Major moments in Steps 1 – 5
STEP 1 LEADERS IDENTIFY LARGE STAKEHOLDER

convene STAKEHOLDERS GROUP CONVENES
stakeholders
STEP 2 CREATES SMALL PRIORITIZES EFFECTS, BRAINSTORMS

collectively DESIGN TEAM LIKELIHOOD, SEVERITY EFFECTS
brainstorm
STEP 3 SMALL DESIGN TEAM REDESIGNS

conceptualize CONCEPTUALIZES EFFECTS INTERVENTION
effects
STEP 4 LARGE STAKEHOLDER GROUP

INTERVENTION RECONVENES TO CONSIDER
adapt and DESIGN FINALIZED
redesign THE REDESIGN
STEP 5 EVALUATION DESIGN

determine INITIATED
indicators
The process evaluation component addresses
Part II: The evaluation
adequacy and helps explain: what processes of
design change lead to observed effects; why outcomes
might not have changed; and if the intervention
Step 5. Determine indicators: Once
is working as expected within and across
the intervention has been designed or
the sub-systems. For instance, the process
re-designed using the systems perspective,
evaluation could address the governance sub-
the design team, now assisted by researchers
system in terms of looking at policy formulation,
and/or evaluators, need to develop the key
programme acceptability among stakeholders,
research questions to inform the evaluation.
priority setting at various levels, and guideline
They must decide what processes, issues and
availability. It could address the financing
contexts are important to track over time in
sub-system by examining financial flows,
the evaluation, considering the major positive
sustainability and (re)allocations of additional
and negative effects hypothesized and discussed
funds to scale-up technologies, infrastructure and
during steps 1-4. Once the research questions
supplies in the system. For the human resources
have been agreed upon, the next issue is to
sub-system, the training and availability
d e c i d e u p o n n e c e s s a r y i n d i c a t o r s, a n d
of guidelines, the extent of training coverage
the potential data sources for these indicators.
and actual financing could all serve as indicators
Table 3.2 (following Step 6) shows indicators,
to track the degree of implementation. For
data sources and evaluation types for the P4P
the other sub-systems, the process evaluation
case illustration.
could focus on the process of implementation
Step 6. Choose methods: Once the indicators and how this affects different aspects of service
and potential data sources have been agreed delivery over time – including provider
upon, the next decision is selecting the best motivation, technical and human quality of care.
methods to generate the required data.
The context evaluation component can help
To deal with the complexity of large-scale explain whether the observed effects are
system-level interventions, the evaluation should due to the intervention – and if not, why not?
include four components: a process evaluation – essential to ensuring the plausibility of
(for adequacy); a context evaluation the evaluation’s conclusions. The importance of
(for transferability); an effects evaluation context within the system can never be over-
(to gauge the intervention’s effects across all estimated since the personal and institutional
sub-systems); and an economic evaluation contexts shape the behaviours of the actors
(to determine value for money). This requires as much as the structural context of the system.
baseline, formative (during early implemen- This requires ruling out the influence of external
tation) and summative (during advanced factors and bringing into play the importance of
implementation) evaluations, with special comparison areas and adjusting for confounders
attention during the formative evaluation phase (69). A context evaluation is also essential for
to generate lessons in order to fine-tune the eventual transferability of the results
the intervention – to improve performance by documenting circumstances in which
and to understand how the intervention really the intervention operated, what effects
works given the characteristics of systems the intervention in this context produced, and
(see Figure 3.4). for whom the effects were observed (17).

The effects evaluation component is the one by looking at incremental costs of implementing
most commonly conducted and understood the intervention from the provider and wider
and needs little elaboration here. It basically societal perspectives (including the perspective
describes and quantifies the intervention’s health of households) compared with the status quo
outcomes as well as its impact on effective or other alternatives. It thus addresses efficiency
coverage, quality of care, and equity – issues concerns, one of the overall outcomes of
that correspond with the overall goals/outcomes the health system framework (26;70). It can
of the health system. also include a financial assessment of
the programme’s sustainability, and comparison
The economic evaluation component
measures the intervention’s cost-effectiveness of its cost per capita to other services.
Figure 3.4 Key components and generic research questions for evaluations
KEY COMPONENTS SOME KEY RESEARCH

OF EVALUATION QUESTIONS
What is the state of the policy process?
PROCESS EVALUATION What is state of implementation (adequacy)?
IMPROVED PERFORMANCE
RECOMMENDATIONS FOR
What changes could result in effects?
What facilitates / impedes the intervention?
CONTEXTS EVALUATION What other co-interventions are relevant?
What else is changing in the system?
What are the positive effects on coverage?
EFFECTS EVALUATION What health / equity benefits result?
Are there any unintended consequences?
ECONOMIC EVALUATION Is the intervention a good use of resources?
62
Table 3.2 A selection of research questions, indicators and data sources for the P4P intervention
Type of Key research questions Quantitative indicators Qualitative indicators Data Source
evaluation
Process Is P4P being implemented as intended? n

Availability of implementation n
Method of allocating bonus n
In-depth interviews and FGDs
guidelines at appropriate levels of payments within a health facility n
Health facility survey
the health system n
Who receives bonus payments n
n
Proportion of stakeholders who have n
Punitive methods, if any, for dealing n
received training on P4P at with misreported indicators when
appropriate levels of the health system n
Exit interviews
identified by management
n
Time between submission of six
monthly reports and payment of
SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

bonuses
n
How much bonus do health facilities
and health workers get, by cadre
n
Quantity of bonus payments made to
health facilities
n
Extent of system leakage; frequency of
receipt of bonus by non-eligible
facilities or staff
n
Frequency of managerial identification
of mis-reporting of performance
Contexts What other financing or human resource n

Training coverage n
Type of trainings n
Document review
interventions are underway during n
FGDs
the P4P extension?
evaluation
Contexts What other service delivery interventions n

Training coverage n
Type of trainings n
Document review
targeting maternal and neonatal n
FGDs
interventions are underway during
the P4P extension?
What other service delivery interventions n

Training coverage n
Type of trainings n
Document review
are made for non-target services? n
FGDs
What measures have been taken to n

Changes made n
In-depth interviews
improve health information systems
n
Document reviews
and their audits?
What other changes in society may effect n

Factors affecting access n
Secondary document review
access and utilization of health services? to concerned health facilities, (e.g. household budget surveys,
e.g. economic, availability of district records, etc.)
public transport
n
Location of health facilities,
compared to other types of
providers
CHAPTER 3 APPLYING A SYSTEMS PERSPECTIVE TO DESIGN AND EVALUATE HEALTH SYSTEMS INTERVENTIONS
63
64
evaluation
Effects What is the effect of P4P on provider n

Some quantitative measures n
Perceived impact of P4P on provider n
motivation and trust relations? of motivation motivation over time n
n
Possible variations in perceptions
of key stakeholders about the
adequacy of the bonus level over
time
n
Impact of P4P on trust between
stakeholders
What is the effect of P4P on resource n

Amount of funds available at facility n
Method of budget allocation and n
SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

allocation? level and patterns of expenditure priority investments at district level n
Document review
within facilities
What is the effect of P4P on service n

Average consultation duration in n
Patient satisfaction with targeted n
quality and availability? minutes for targeted and non-targeted and non-targeted services n
Household survey
services before and after intervention n
Patient reports on costs of services n
Exit interviews
n
Proportion of patients receiving drugs
or treatments at health facility for n
Time motion study
targeted and non-targeted services
n
Rates of referral for delivery care
n
Structural quality score
n
Time spent by health workers on act-
ivities associated with bonus payment,
vs. activities with no associated bonus
n
Total number of health workers in
facility
evaluation
n
User charges for targeted and non-
targeted services
Effects What is the effect of P4P on coverage? n

Coverage rates of services linked to n
Willingness of staff to move to n
HMIS
bonus payment (including c-section under-staffed, more remote facilities n
Health facility survey – record
proportions) by socio-economic status as a result of the P4P scheme review
n
Coverage rates of non-targeted (ideally by identifying staff who
n
Household survey
services (including ante-natal care, have actually moved for this
family planning, and total out- and reason). n
Document review
in-patient admissions)
Economic Is P4P cost-effective? n

Overall economic status of target n
Financial accounts for P4P and
Is P4P affordable? population of facilities receiving higher comparator intervention
What is the optimal P4P bonus level? level bonus payments and those n
District budget per capita for
receiving lower levels, or not receiving different services
bonus payments n
Document review
n
P4P as proportion of provider income n
Household survey
n
Effect of P4P on proportional spending
in overall health budget
n
Incremental cost-effectiveness of P4P
compared to other measures of
improving quality of care or increasing
coverage, or even wider range of
interventions
n
Cost per additional coverage
n
Cost per capita
CHAPTER 3 APPLYING A SYSTEMS PERSPECTIVE TO DESIGN AND EVALUATE HEALTH SYSTEMS INTERVENTIONS
65
Step 7. Select design: There are some As observed above, however, randomization
evaluation designs particularly well-suited to alone will not illuminate the complex causal
system-level interventions. These tend to come pathway between intervention and sub-systems;
more from the epidemiologic and health systems will not easily allow for delays in effects or
research tradition than from the monitoring changes over time in contextual factor; and is
and evaluation tradition. In this step, we discuss further weakened by the constant reform of
the most common designs – probability designs, health systems typically subject to a variety of
plausibility designs, and adequacy designs. interventions in multiple sub-systems at the same
Probability designs. Purely experimental time. RCTs alone simply lack the operational
methods – randomized controlled trials (RCTs) plausibility and generalizability to other contexts
– are considered the “gold standard” for unless special attention is paid to documenting
evaluations in health research and have been contexts (51).
used primarily in the evaluation of intervention Partly for the above reasons, purely experimental
efficacy and occasionally for health systems randomized controlled trials of health systems
strengthening interventions. However, RCTs tend interventions are not common (73). While there
to be carried out in limited areas and over are examples where RCTs have been successfully
a relatively short period of time, making them used to evaluate such interventions at scale (74),
often ill-suited to evaluating interventions with in many circumstances, they are simply
system-wide effects, especially those with long inappropriate, inadequate, possibly unethical or
delays in expected effects or where causality is impossible to conduct (75).
complex and difficult to establish. Probability
In large-scale system-level interventions,
designs are thus not often an ideal approach
a phased introduction is typical. Interventions
to evaluation using the systems perspective.
rolled out nation-wide cannot be launched
everywhere simultaneously and often take one
BOX 3.6 THE P4P or several years to reach all administrative areas
INTERVENTION –
of a country. It may then be possible to use
PROBABILITY
a randomized step-wedge design. In a step-
DESIGN
wedge design, an intervention is sequentially
expanded to administrative regions over
The evaluators felt it might be possible
a number of time periods. Ideally, the order in
to apply a cluster randomized controlled
which the different geographic administrative
design for evaluation, depending on how
areas receive the intervention is determined
the intervention is actually implemented
at random and, by the end of the random
at scale (33;70-72). Such a design would allocation, all areas will have received
work if, for example, it were politically the intervention. Step-wedge designs offer
acceptable to randomly assign a set of a number of opportunities for data analysis,
intervention areas (e.g. districts) – each as well as for modeling the element of time
would introduce identical financial on the effectiveness of an intervention. However
performance contracts, with a control there are very few examples of step-wedge
group composed of areas not receiving designs applied to the evaluation of a system-
level intervention (76).
the intervention.

Given these very real limitations, most system- designs over the long term when the intervention
level interventions usually roll-out in a non- is rolled out under conditions closer to routine.
random manner – often in the easiest-to-reach Such designs are most useful when there are
areas first and then progressing to more difficult relatively rapid and widespread effects in large
areas, making time series and equity effects more populations; where confounding is unlikely to
difficult to interpret. There is also a learning explain observed effects; where selection bias is
and maturation phenomenon that changes unlikely; and where there are objective measures
the intervention over time in such real-world of exposure. Even when effects are widespread,
implementation. It has been shown that this non- results should still be interpreted cautiously,
random extension can result in completely especially if those effects are unexpected.
different conclusions, for example, on equity Plausibility designs are in a sense both
during the early, mid- and late phases of observational and analytical.
the roll-out (Box 3.1; Figure 3.5). Adequacy designs. Adequacy designs are
Plausibility designs. In recognition of these important for complex interventions that consist
constraints on RCTs, plausibility designs have of a suite of associated activities or interventions,
emerged as the most suitable substitute for and are usually included in plausibility designs.
evaluating the effectiveness of complex, large- These designs may be useful for policy-makers
scale, system-level interventions in real-life when there is no improvement in the outcome of
settings. Plausibility designs demonstrate that interest, or where there is a large improvement in
a specific intervention, when adequately a relatively simple outcome combined with
delivered, is effective in its context (69;77;77-80). a relatively short causal chain, and where
They often include descriptive studies on confounding is unlikely. Although many system-
the adequacy of the intervention’s delivery level interventions have long causal chains and
(are expected processes taking place?) but then delays in effect, adequacy designs, although
go beyond with additional observational studies necessary, are rarely sufficient on their own.
(are the observed changes plausibly due to They are descriptive and do not allow for control
the adequacy of the expected processes?). of confounders.
Plausibility designs require comprehensive
documentation of contexts to exclude external BOX 3.7 THE P4P
factors as the explanation for observed changes; INTERVENTION –
they also need a comparison area or group that EVALUATION
allows adjustment for confounding factors and TYPE
identification of contextual factors critical to
an intervention’s success (or failure) alongside Given this consideration of three different
conceptual frameworks for how the intervention designs, the design team determine that
is expected to have an effect. Even in situations a plausibility design is the most practical
where there is convincing evidence from RCTs option for the evaluation of the P4P
at the initial phase of an intervention’s intervention.
development, it is important to do plausibility
Table 3.3 Summary of characteristics for optional evaluation design choices
for the P4P intervention
Design Characteristics Advantages Disadvantages
Probability Cluster (district) randomized Controls for confounders

n Delays full implementation
n
controlled trial (RCT) design Generates strong evidence
n Does not explain causal link
n
applied to all components of of efficacy between intervention and
the intervention Probability of confounding
n outcomes
can be estimated Misrepresents dynamic
n
properties of the system
Fails to take account of
n
contextual and emergent
aspects
Challenge for health system
n
policies acting at district
level or higher
Po l i t i c a l a c c e p t a b i l i t y
n
difficult
Cluster randomized controlled May be politically more

n Cannot control for effects
n
design applied to indivi- acceptable as all areas of cash payments per se
dual components of the receive the same funding except through before-after
intervention (e.g. P4P with study
and without performance
contracts)
Randomized step-wedge May be more politically

n As with all RCTs, contextual
n
controlled trial ac c e p ta b l e i n ter m s o f documentation needs to be
roll-out added
Plausibility Internal comparison (e.g. early Controls for most con-

n Difficulty controlling for
n
and late starter districts) founders inherent differences
All plausibility designs
n between early starters
include measures of and late starters
adequacy and context Relies on natural phasing-in
n
External comparison (e.g. May be more acceptable

n Need to control for con-
n
comparison districts) than randomization founding or inherent
differences between
intervention and comparison
areas
Interrupted time-series Allows evaluator to control

n Requires reliable data on
n
for the natural trend core indicators up to a year
that would have occurred before the start of the
anyway, in the outcome intervention, to allow for
indicators trend estimation
Adequacy Historical comparison (before Does not require political

n Can only control quali-
n
and after study) ”buy in” tatively for confounders,
hence assessment of effects
is less robust. Absence
of baseline in midstream
evaluation is often a problem

Step 8. Develop plan and timeline: Once Evaluation plan. There is also a need after
decisions on the research questions, indicators, the baseline evaluation to include
data sources, methodological approach and type a formative evaluation in the intervention’s
of design have been made, it is then possible early stages (to fine-tune the intervention and
to identify the necessary disciplines and expand adapt its implementation). To some extent then,
the partners required to complete the evaluation the formative evaluation becomes part of
plan. the intervention, and makes the impact
evaluation more complex. But this is relevant
Timing of evaluations. The pace at which because of the potential for variation in
health system strengthening investments and
implementation in complex systems in different
innovations occur is quickening. Most often, settings. Finally, since complex, system-level
system-level interventions are planned, funded, interventions will be variously implemented
and launched before its accompanying evaluation or experienced in different facilities or areas,
can be properly commissioned, designed the impact evaluation should deliberately
and funded. The majority of evaluations, if done, estimate how its effects vary across sites or
have no baseline evaluation because areas – what the maximum and minimum
the evaluations often start mid-stream, long effects are – rather than just focusing on
after the intervention has been rolled out. the average effect (which might hide different
An additional timing weakness occurs when experiences). This would allow for richer
evaluations do not run long enough to detect discussion of replicability in other settings –
indirect or long-term effects that often take time e.g. when the intervention is rolled out in
to develop. other parts of the country – and offer some
guidance on how to support interventions
elsewhere.
BOX 3.8 NON-RANDOM ROLL-OUT

OF INTERVENTIONS AND
THE TIMING OF EVALUATIONS
The Tanzania National Voucher Scheme (TNVS) is a national programme delivering vouchers
for subsidised insecticide-treated nets to women at antenatal clinics. It was scaled up
gradually over the period of about 18 months starting in October 2004.
The evaluation of the TNVS was designed to capture both the levels of coverage achieved
by the voucher scheme, and its socioeconomic distribution (80). For the evaluation, districts
were classified into three equal-sized groups, according to their planned launch date,
and a random sample of seven districts from each of these three strata was selected.
Household, facility and facility user surveys were conducted in the 21 evaluation districts (81)
and socioeconomic status of beneficiaries was measured using a combination of household
asset ownership and housing conditions, and a single asset index was estimated for the whole
sample. Households were divided into quintiles according to their value of the continuous
SES index estimated using principal components analysis over the whole sample of districts.
BOX 3.8 NON-RANDOM ROLL-OUT
(CONTINUED) OF INTERVENTIONS AND
THE TIMING OF EVALUATIONS
This SES analysis allowed evaluation of the socioeconomic distribution of households

according to the programme launch date – “early,” “middle” and “late”. The predominance
of poorest (Q1) in the “late” launch group, and the least poor (Q5) in the “early” launch
districts shows how the non-random roll-out plan favoured the least poor parts of the country
first. The extended roll-out period, probably essential in a country the size of Tanzania,
means that many of the poorest districts and households received the intervention up to
18 months later than the first ones. This evidence about roll out and SES also demonstrates
the challenge of programme evaluation when scale up is non-random: programme exposure
is positively correlated with socioeconomic status, making it important to control for this factor
when undertaking analysis of programme impact and sustaining the evaluation long enough
to make valid conclusions (80).
Source: Text provided by Hanson K, Marchant T, Nathan R, Bruce J, Mponda H, Jones C. and Lengeler, C, and
presented in part at the Swiss Tropical Institute Symposium on Health System Strengthening: Role of conditional
cash incentives? November 27, 2008, Basel, Switzerland.
Figure 3.5 Socioeconomic distribution of households by launch of insecticide-

treated nets (ITNs) voucher scheme in the United Republic of Tanzania
Q1
Q2
35
Q3
30
Q4
25 Q5
20
15
10
Early Middle Late

Step 9. Set a budget: This step can Conclusion
sometimes be part of step 8, but in a competitive
grants process it may not be possible to know This chapter provides further detail on how
the cost implications of the evaluation until step a systems perspective can create a more dynamic
8 is completed. Ideally the evaluation budget design and evaluation of a system-level
should revert to the design group for inclusion intervention intending to strengthen the health
with the intervention budget. This will ensure system. The Ten Steps to Systems Thinking
the funding is in place before the intervention demonstrate practically how to link the acts
is implemented. of planning, design and evaluation in a more
coherent, participatory and system-centred way.
Step 10. Source funding: The last step
is to encourage an evaluation that is front- Beyond the importance of the intervention
loaded and funded before the intervention design, this Chapter calls particular attention
commences its roll out in order to provide to the centrality of evaluation in documenting
the counterfactual baselines for all measures. and assessing effects. Ideally, evaluations should
One consequence of the improved intervention be designed, funded and started before
design and improved evaluation design the intervention is rolled out in order to provide
is the likely higher cost for both (but higher adequate baselines and comparators. This is
probability of successful implementation and essential if we are to fully demonstrate
accurate evaluation). the effectiveness of the intervention and
its system-wide impacts. Intervention and
evaluation funders should be prepared for the
higher costs of comprehensive evaluations
addressing the broader effects of health system
strengthening. Evaluations that fail to capture
and assess the full systemic effects of
an intervention may be highly misleading.
The systems perspective will reward its funders
and designers with a comprehensive assessment
of whether the intervention works, how, for
whom, and under what circumstances.
4
systems: Challenges and
opportunities in real-world
settings
Key messages
With leadership, conviction and commitment, systems thinking

n
can open powerful pathways to identify and resolve health
system challenges.
Health system stewards can use the systems thinking

n
perspective to increase local ownership of multi-stakeholder
processes and respond to the dynamic of disease-specific,
sometimes donor-driven “solutions”.
Engaging "street-level" policy implementers at the design

n
stage of new interventions can enhance ownership of the
intervention and increase the potential for its successful
implementation.
Strengthening the governance and leadership roles of health

n
systems stewards is a crucial step in strengthening health
systems.
“The first of the ‘fundamental impediments’ to the adoption of systems
thinking is that we’re prisoners of our frame of reference”
Barry Richmond, 1991 (82)
In this Chapter, we do not propose systems Many still tend

Introduction to dismiss systems
thinking as a panacea to resolve or restructure
thinking as
Previous Chapters of this Report have the relationships at the heart of a health system; too complicated for
emphasized the valuable contributions of rather, we use it as a tool to identify where any practical purpose
systems thinking in designing and evaluating some of the key blockages and challenges or application.
interventions to strengthen health systems. in strengthening health systems lie. Beyond
Although the rationale and potential for applying the overarching resistance to systems thinking –
the systems perspective in public health are and how it might upset the relationships that
not new (22;29;34-37), many practitioners fund and support the dominant approaches
still tend to dismiss it as too complicated to improving health – we identify four specific
or unsuited for any practical purpose challenges in applying a systems perspective,
or application (22). and suggest how this perspective can convert
Fo l l o w i n g C h a p t e r 2 ’s b r o a d o v e r v i e w them into opportunities to strengthen health
of systems thinking, and the “Ten Steps to systems.
Systems Thinking” illustrated in Chapter 3, this
Chapter discusses systems thinking in the real
world – where the pressures and dynamics BOX 4.1 SELECT
of actual situations often block or blur CHALLENGES
the systems perspective. Systems thinking IN APPLYING
must resonate with existing experiences A SYSTEMS
in developing countries and account for PERSPECTIVE
present challenges in its application and
integration. For those who wish to improve n
Aligning policies, priorities and
present realities and relationships using perspectives among donors and
the systems perspective – from researchers national policy-makers
to system stewards to international funders – n
Managing and coordinating
this Chapter underlines how systems thinking partnerships and expectations
can identify and resolve various health system a m o n g s y s t e m s t a ke h o l d e r s
challenges, and highlights some particularly
n
Implementing and fostering
innovative approaches and experiences.
ownership of interventions at
the national and sub-national
Part I: Select challenges level
in applying a systems n
Building capacity at the country
perspective level to apply a systems analytic
There are a host of challenges to applying perspective
a systems perspective in developing countries,
ranging from prevailing development paradigms
to issues around intervention implementation.
CHAPTER 4 CHALLENGES AND OPPORTUNITIES IN REAL-WORLD SETTINGS 75

BOX 4.2 DEFINING HEALTH SYSTEMS STEWARDS
In this Chapter we focus on national health system stewards, which we understand

as policy-makers and leaders responsible for providing strategic direction to the system
and its concerned stakeholders. These are typically from government (e.g. senior Ministry
of Health officials, a district commissioner, a hospital administrator), but may also include
other stakeholders, e.g. civil society and the private sector. System stewards are "information
providers and change agents, linking the general public, consumer groups, civic society,
the research community, professional organizations and the government in improving health
of the people in a participatory way"(83).
1. Aligning policies, priorities and harmonizing the policies, priorities and

perspectives among donors and perspectives of donors with those of national
national policy-makers policy-makers is an immediate and pressing
concern – though with few apparent solutions.
“HIV, TB and Malaria have taken almost 90%
of our time, not to mention that they have For example, there is increasing evidence that
also taken most of our budgetary money to while funds for AIDS, TB and Malaria are indeed
the extent that we have actually neglected saving lives (87), they typically come without
what we call non-communicable diseases" sufficient strengthening of health systems to
Ministry of Health official, Zambia,
sustain these gains. In addition it is increasingly
October 2007 (84).
argued that the selective nature of these funding
There is a tension in many developing country mechanisms (e.g. targeting only specific diseases
health systems between the often short-term and subsequent support strategies) may
goals of donors – who require quick and undermine progress towards the long-term goals
Though additional measurable results on their investments – of effective, high-quality and inclusive health
funding is particularly and the longer-term concerns of health system systems (86;88;89). Even where this funding
welcome in low-
stewards. That tension has only heightened in has strengthened components of the health
income contexts,
it can often recent years, where the surge in international system specifically linked to service delivery
greatly reduce aid for particular diseases has come with in disease prevention and control – such as
the negotiating
ambitious coverage targets and intense scale-up specific on-the-job staff training – recent
power of national
health system efforts oriented much more to short- than long- research suggests that the selective nature of
stewards in term goals (85;86). Though additional funding these health systems strengthening strategies
modifying proposed
is particularly welcome in low-income contexts, has sometimes been unsustainable, interruptive,
interventions
or requesting it can often greatly reduce the negotiating and duplicative, putting great strains on
simultaneous power of national health system stewards in the already limited and over-stretched health
independent
modifying proposed interventions or requesting workforce (84;86;88;90;91). Additionally,
evaluations of
these interventions simultaneous independent evaluations of these f o c u s i n g o n “ ra p i d - i m p a c t " t r e a t m e n t
as they roll out. interventions as they roll out. In many countries, interventions for specific diseases and ignoring

investments in prevention may also send linked to their specific health outcomes of
sharply negative effects across the system’s interest (84;86). However, recipient countries
building blocks, including, paradoxically, have so far been slow to request these funds for
deteriorating outcomes on the targeted diseases systems strengthening. Out of US$4.2 billion
themselves (88). of Global Fund resources earmarked for health
Many of these issues have been recognized systems strengthening since 2007 – such
internationally, and a number of donors have as building infrastructure, improving laboratories
agreed to better harmonize their efforts and align and the development and support of monitoring
with country-led priorities – as outlined in 2005’s and evaluation systems – only US$660 million
Paris Declaration on Aid Effectiveness (92). has actually been committed for “cross-cutting”
However, a 2008 report showed that, although health system strengthening actions that apply
some progress has been made in applying the to more than one of the three diseases (93).
Paris Declaration principles, it has been slow and This may perhaps reflect similar issues at
uneven (85). For example, the report found little the country level – those applying for funds for
evidence that donors had improved or made use disease-specific programmes may not work
of existing structures or health information closely with those seeking to strengthen health
system of recipient countries – and in some cases systems as a whole.
had even created parallel systems to collect the It is here where the systems perspective can best
data they needed. This often creates inefficiency support health systems stewards. If donors are
and duplications, and fails to harmonize and use increasingly committed to health system
data locally or empower countries to strengthen strengthening, then system stewards must
their own Health Information Systems. Similar maximize this opportunity. The “Ten Steps
negative effects have also been suggested to Systems Thinking” can usefully guide and
in other parts of the health system, for instance frame discussions between system stewards and
in the areas of finance, service delivery and donors, and lay the groundwork for a system
medical technologies (89). strengthening initiative that all can agree on.
Change in the process and the nature of Steps 1 (convene stakeholders) and 2 (collectively
the relationship between donors and countries brainstorm) in particular can address existing
requires time, focused attention at all levels, paradigms and the new relationships required
and a determined political will. "This means to transcend them. System stewards must lead
more than just putting more pressure on the gas discussions among concerned stakeholders –
pedal. It requires a shifting of gears"(85). And domestic and international – on the merits
there are indeed some early signs that the gears of different interventions, but also in assessing
are shifting. For instance, several funding bodies the potential effects of the intervention on each
– e.g. the Global Alliance for Vaccines and health systems building block and ensuring that
Immunization (GAVI) and the Global Fund to evaluations of these interventions are undertaken
Fight AIDS, Tuberculosis and Malaria (GFATM) – as soon as they are rolled out. Strong national
have agreed to give health system strengthening governance through the leadership of health
greater prominence within their disease-specific systems stewards is central in overcoming
initiatives. This should allow for greater flexibility the existing set of relationships between funders
in using their funds to strengthen health systems, and recipients.
even if they still require that activities are tightly

2. Managing and coordinating to their own funding. "This created a huge
partnerships and expectations problem,” stated a staff member of Uganda’s
among system stakeholders Ministry of Health, with “too much double
counting” (91).
“Donor collaboration has aimed
at harmonizing data tools for use Developing and maintaining a culture of open
at facilities and designing new forms and effective partnerships among a variety
for use in the health management of national and international stakeholders
information systems. Even so, reports is sensible practice for health system stewards.
suggest that the donors have been
They can provide this leadership by emphasizing
competing with each other to get results
attributed to their own funds, creating the systems perspective for interventions in
a burden on health workers“ (91). the health system; by fostering open discussions
and transparency in expressing competing
While building and supporting partnerships is
objectives and mandates; and by providing
at the heart of applying a systems perspective
the right incentives for data sharing and
to strengthening health systems, managing and
reconciliation.
coordinating those partnerships – and their
expectations – when designing interventions
3. Implementing and fostering
and appraising evaluation findings can pose
ownership of interventions at
a daunting challenge. Different partners will have
the national and sub-national level
different mandates, priorities and perspectives,
all of which may be legitimate. The particular “Implementers of policies influence how
challenge facing health systems stewards lies policies are experienced and their impacts
achieved. … the apparently powerless
in effectively managing stakeholder participation
implementers, at the interface between
and contributions to the design and evaluation of bureaucracy and citizenry, are difficult
these interventions, ensuring their expectations to control because they have a high margin
are met and the process is “owned” without of discretion in their personal interactions
compromising objectivity or the needs of with clients, allowing them to reshape
the system itself. policy in unexpected ways" (46).
For instance, donors are often caught between As discussed in Chapter 2, one of the main
their need to demonstrate rapid progress challenges facing a complex system is policy
and success in the implementation of funded resistance, where seemingly obvious solutions
interventions and their commitment to may fail or worsen the situation they were
strengthening the health systems of recipient designed to address (43). Research in the United
countries (85). Several recent reports have shown Republic of Tanzania explored this phenomenon
positive signs of increased donor collaboration in understanding why the implementation rates
in the area of health information systems, of community health insurance funds saw less
particularly in harmonizing data tools for use than 10% enrollment after 10 years of
at the facility level – for instance in monitoring implementation (46). The authors showed
patients on antiretroviral treatment (ART) that the actions of district managers influenced
(24;91). However, some countries have how the policy was translated to implementation,
experienced difficulties in managing competition directly contributing to the low implementation
among donors and governments in attributing rates. Interviews with district managers revealed
actual outcomes (e.g. number of people on ART) their underlying reluctance to implement and

support the new policy. They judged it as difficult power over them, exerted from above, that made
t o i m p l e m e n t , a n d b l a m e d t h e c e n t ra l their leaders look good, predominantly at their
government for not addressing its financial own expense (94).
sustainability. Although district managers were The coping behaviour of "street-level” policy
well aware of the policy, they often ignored implementers (See Box 4.3 for a definition)
it and did not view it as part of their mandated frustrated with top-down decision-making
district activities. Instead, they saw it as processes also reflects a lack of local ownership
an additional and separate activity operating of the policy (97). Clearly some stakeholders
with its own funds – "like an NGO," as one essential to implementing an intervention
manager remarked. Consequently, district funds had not been involved in its design. Overcoming
were not mobilized to provide the necessary the resistance of these implementers comes
infrastructure for the community health with understanding and incorporating their
funds, which led to little public awareness of perspective – early and adequately. In calling
the programme, and no criteria or guidelines for a multi-stakeholder approach to the design
for fee exemption. and evaluation of system-level interventions,
Further analysis revealed that district managers the systems perspective seeks to give voice
felt they had little time to prepare for these to those who are absolutely critical
activities and described the introduction t o i m p l e m e n t a t i o n p r o c e s s e s. I n d e e d ,
of the CHF as overly rushed. "The CHF came multi-stakeholder involvement is a crucial
to us like a fire brigade,” reported one of e l e m e n t t h r o u g h o u t t h e “ Te n S t e p s t o
the ward-level interviewees. “The programme Systems Thinking”: identifying and involving
is good but implementation is beset with key stakeholders concerned with or affected
problems." These observations were consistent by the intervention’s implementation is
with interviews at the national level describing essential, particularly throughout Steps 1-4.
the considerable political pressure to implement
the intervention after promises had been made
during an election campaign. BOX 4.3 DEFINING
" STREET-LEVEL "
There are several other manifestations of this
POLICY
phenomenon (94-96). South Africa’s slow
IMPLEMENTERS
progress in reducing maternal mortality despite
more than a decade of intensified efforts have
"Street-level" policy implementers –
partly been attributed to the practices of health
or "street-level bureaucrats" as used
care workers (94), who have reacted in
in the field of sociology (97) – is a term
unexpected ways to ongoing structural and
for those "service providers who work
financial reforms in the public sector. While the
government saw these reforms as a means to at the implementation end of policies
improve financial management and health care, that they have not designed, and who
front-line health workers perceived a very use the degree of relative autonomy
different set of meanings. They saw little value in that they possess to reinterpret these
the reform policies, feeling stress and fear that policies and to revise guidelines
a n y m i s t a ke s w o u l d l e a d t o t h e i r o w n according to their own priorities"(96).
imprisonment. They saw the policies as unilateral

4. Building capacity at the country partnerships is mirrored at the international level.
level to apply a systems analytic Robust, multi-disciplinary international
perspective partnerships between research institutions –
often hugely successful – require a substantial
“Strengthening research capacity in developing
investment of time and resources, and as such
countries is one of the most powerful,
cost-effective, and sustainable means are typically not encouraged by funders or
of advancing health and development” (98) embedded within institutional reward systems
in the developed world (104). Though there are
Health systems strengthening efforts
some notable examples of thriving 'North-South'
in developing countries often encounter
collaborations and capacity building initiatives
one or more central capacity constraints:
(100;103;105;106), many research funding
limited multi-disciplinary technical skills
bodies still do not see these collaborations as a
compounded by weak research partnerships
priority (100;105). Without this funding for
and collaborations; poor quality and availability
collaboration, and without increased investments
of data (75;99); the lack of innovative research
methods (100); and limited skills in building and from domestic sources, existing capacity
managing partnerships. These problems are constraints will continue as a significant drag
deepened by the fact that resources for capacity on health systems strengthening, including
building are still mainly driven by international diminished leadership roles in intervention
sources, providing little or no leverage for design and evaluation, and weak ownership
developing countries on the selection of priorities and relevance of the generated information for
for research or skill development or on policy-making (100;102). An encouraging sign
the proportional use of resources for capacity for increased domestic efforts to strengthen local
building (100-102). "Anyway … it is the donors capacity to generate and use evidence from
who decide what the money is spent on … so research is the recent announcement by
why set priorities?" is a common sentiment the President of the United Republic of Tanzania
among developing country researchers (103). to triple domestic resources currently spent
H o w e v e r, t h e a b i l i t y o f c o u n t r y t e a m s on science and technology (from 0.3% to 1%
to undertake research and analyse their own of GNP) (103).
data is crucial for understanding what works,
for whom, and under what circumstances – and Poor data availability and quality
for monitoring and addressing problems along E va l u a t i o n s o f c o m p l e x h e a l t h s y s t e m s
the way (100). interventions depend on a wide range of
functional data platforms and monitoring
Limited multi-disciplinary skills systems to provide up-to-date information on all
and weak research partnerships sub-systems, as well as relevant contextual
and collaborations
factors (such as other ongoing health or health-
While there are indeed some strong research related initiatives). Basic routine data collection
skills in developing countries, many researchers systems, including the health information system,
tend to operate in disciplinary “silos,” with little procurement and supply chain management
institutional incentive to undertake collaborative, data, and financial management systems
multi-disciplinary projects and approaches.
The absence of these essential in-country

are still weak and disconnected in many Learning skills in building and
countries, often storing limited and incomplete managing partnerships
information (91). Good quality in-country
Building and managing partnerships is essential
databases for even basic health service reporting
to the systems perspective, as illustrated
are also often lacking (24). This is a crucial
above. This involves specialized skills such as
barrier, not only for high quality evaluations,
the facilitation of interdisciplinary meetings
but also for monitoring and evaluating
and discussions involving complex group
the health system’s basic functions. Investing
dynamics, different perspectives and motivations;
i n d a t a a v a i l a b i l i t y, q u a l i t y a n d u s e
consensus building without excluding different
is a long-term prospect, but critical to
views; and most importantly, instilling ownership
more efficient and coordinated efforts
of the eventual products and processes. These
in improving health and health systems.
skills and techniques are not typically taught
It would also reduce the burden on the already
in formal institutions and usually require hired
over-stretched health workforce by avoiding
external support to lead or impart them.
short-term “solutions” that create parallel
Comprehensive and accessible information
systems (91). on the available resources to acquire these skills,
and whether there is a need for additional
Need for innovative methods
resources to meet the partnership-building
Another more global challenge is the need needs of systems stewards, is a top priority.
for new methods development better suited
to the complex nature of health systems
interventions (100). For example, while capacity
for conducting household surveys may exist
in some countries (e.g. through Demographic
and Health Surveys and other ongoing
community-based surveillance systems),
capacity for conducting qualitative research
is typically less developed. Even in cases where
sufficient qualitative skills exist in-country,
the focus has traditionally been in using these
skills in small-scale studies involving local
communities, and much less for complex
health systems issues (107;108). Encouraging
the development and publication of studies
using innovative methods applicable to complex
interventions with system-wide effects is critical
to increasing the evidence and improving
the quality of this body of knowledge. This calls
for increased support for this type of research,
both in terms of funding and setting research
priorities.

Part II: Innovative 1. Convening multiple
constituencies to conceptualize,
approaches to applying design and evaluate different
the systems perspective strategies
While the challenges to applying a systems Chapter 3 argued for the importance of
perspective are indeed pressing, and a full consulting and involving a wide range of
understanding of its utility still in its infancy, stakeholders in the design of system-level
there are nonetheless some vital opportunities interventions and interventions with system-
for advancing this approach, and examples wide effects. This process can elicit valuable
demonstrating its value. Key developments over insights on the possible synergies and negative
the past several years have explored and ramifications of the proposed intervention,
highlighted the many possibilities of a systems and discuss ways of amplifying or mitigating
perspective. These include: these effects – either at the design stage
n
convening multiple constituencies to or during its implementation and evaluation.
conceptualize, design and evaluate different M o s t i m p o r t a n t l y, h o w e v e r, t h i s m u l t i -
strategies; stakeholder process fosters strong partnerships
and a community of stakeholders addressing
n
applying the whole systems view;
an issue collectively, a cohesion and solidarity
n
developing knowledge translation processes;
that itself has strong system-wide effects.
and
Of course, involving a large number of
n
e n c o u ra g i n g a n i n c r e a s e d n a t i o n a l
stakeholders with different views and mandates
understanding of health systems research
i s f a r f r o m s i m p l e. Th e c o n v e n i n g a n d
and increased global support for
brainstorming process is often time-consuming,
strengthening capacity in health systems
politically sensitive and may not in the end lead
research.
to effective or genuine partnerships unless there
are compelling and common goals.
BOX 4.4 INITIATIVE ON THE STUDY AND

IMPLEMENTATION OF SYSTEMS (ISIS)
The National Cancer Institute in the United States of America funded this project to examine
how systems thinking in tobacco control and public health might be applied. Using many
different systems-oriented approaches and methodologies, ISIS was a transdisciplinary effort
linking tobacco-control stakeholders and systems experts. ISIS undertook a range
of exploratory projects and case studies to assess the potential for systems thinking in tobacco
control. ISIS concluded its work with a set of expert consensus guidelines for the future
implementation of systems thinking and systems perspectives.
Source: Greater than the Sum: Systems thinking in tobacco control, 2007 (22).

One successful example of multiple 2. Applying the whole systems view
constituencies successfully conceptualizing,
Another successful example of a systems
designing and evaluating different strategies
perspective comes from the UK government’s
is that of the Initiative on the Study and
Foresight programme, which explored the issue
Implementation of Systems (ISIS) (see Box 4.4).
of obesity and diabetes, and the “whole
These projects created a multi-stakeholder core
systems” view around both (34). Noting
to enhance an understanding of the factors
the ineffectiveness of interventions designed
affecting tobacco use and to inform decision-
to curb individual obesity and the development
making on the most effective strategies
of diabetes as a result, the Foresight programme
to address these factors (29). Aware of
used a systems mapping approach to understand
the promise – and necessity – of a systems
both the biological and the social complexity
perspective in unraveling and mapping
of obesity, using advice and insights from a large
the truly complex and diverse factors influencing
group of experts drawn from multiple disciplines.
health and disease, ISIS is one of a handful
In a qualitative mapping exercise, these experts
of initiatives to prioritize the innovative
ranked the likely impact of different policy
involvement and insights of multiple
options for different scenarios.
stakeholders (22).
The results of the exercise suggested a number
In recognizing the utility of multi-disciplinary
of policy responses that, together, could create
t e a m s i n s o l v i n g c o m p l e x p r o b l e m s,
a positive impact in tackling obesity. However,
ISIS employed "concept mapping" –
no single response generated a high impact
a structured, participatory methodology
o n o b e s i t y p r e va l e n c e i n a l l s c e n a r i o s.
promoting consultation among diverse
A diabetes systems map was developed
stakeholders (109). The process structures
in response, representing a comprehensive
brainstorming across a broad spectrum
“whole systems” view of the determinants
of issues, either in a face-to-face, real-time
of obesity (see the Foresight Programme's
group process or virtually over the Internet.
report (34) for an illustration of how
The next step is to prioritize the issues
the developers took into account feedback
through individual sorting and rating, and then
loops and the interconnectedness between
synthesizing the inputs, presenting the results
different factors). The process confirmed that
back to participants using graphically presented
obesity is determined by a complex multi-
conceptual maps.
faceted system of determinants, where no single
One of the central promises of the concept
influence dominates. The complexity of
mapping approach is its transparency. When
the problem requires a mix of responses, and
widespread Internet access is available to
the study concludes that focusing heavily or
key stakeholders, a larger number of stakeholders
exclusively on one element of the system
can be involved and the results of the ranking
is unlikely to bring about the scale of change
exercises can be easily accessed, reviewed –
required.
and challenged. This promotes a deeper, richer
discussion and likely more buy-in to the process
and the way forward.

3. Developing knowledge respect, and also lays the groundwork
translation processes for appreciating and weighting both evidence
and policy priorities in an open and transparent
"A little knowledge that acts is worth infinitely
fashion (115) – a finding further confirmed
more than much knowledge that is idle."
Kahlil Gibran (1883 – 1931) in a recent survey of organizations that support
Poet Philosopher & Artist the use of research evidence in LMIC policy
development (110).
Both concept mapping and the whole
systems view are cutting-edge approaches
to identifying and resolving key system-level BOX 4.5 MAKING
issues and challenges. A third comes from SOUND
the emerging field of knowledge translation (KT) CHOICES ON
and its investigations into the interface between EVIDENCE -
the research and policy processes. Related
INFORMED
POLICY-MAKING
to systems thinking, KT is a strong modality in
identifying problems, restructuring relationships,
“Over recent years there has been
and encouraging the active and innovative a proliferation of literature focusing
flow of knowledge – in both developed and on knowledge and how to get it into
developing country contexts. health policy and practice (116;117).
As with systems thinking, at the heart of KT For example, in the 1990s the ‘evidence-
lie relationships. KT focuses on developing based medicine’ movement advocated
contextualized knowledge bases, convening the greater and more direct use of research
deliberative dialogues, and strengthening evidence in the making of clinical
capacity in order to create new and common decisions, and this was later broadened
ground for better relationships and partnerships into a call for more evidence-based
between researchers and research-users. 3 policy as opposed to policies determined
t h r o u g h c o n v i c t i o n o r p o l i t i c s. Pa r t
Such relationships can work to localize and
of this interest arose from a perception
contextualize scientific evidence to respond
that even when research provides solutions,
to local circumstances (110;111); improve
these are not necessarily translated into
the way the system itself produces, manages
policy and practice”.
and uses evidence for decision-making;
and, through the mutual identification
Source: Alliance HPSR Flagship Report, 2007 (118).
and production of policy-guided knowledge,
create a deeper appreciation of research
In like fashion, the importance of early
processes at the policy level (112).
and close engagement of researchers
Though this research and policy interface still a n d p o l i c y m a ke r s i n d e v e l o p i n g a n d
requires much more study in the developing evaluating new interventions and policies runs
world (113), a 2002 meta-analysis found throughout systems thinking, featuring in almost
“personal contact” to be the main facilitator every step of the “Ten Steps to Systems
of these research and policy processes, and
its lack as the main barrier (114). Such contact 3
For more information, see the Research Matters
facilitates shared understandings, common K n o w l e d g e Tra n s l a t i o n To o l k i t , a va i l a b l e a t :
http://www.idrc.ca/research-matters/ev-128908-
approaches to solutions, develops trust and 201-1-DO_TOPIC.html

Thinking” discussed in Chapter 3. With KT works towards both evidence-informed policy-
knowledge translation approaches and making and policy-informed research, systems
modalities now proliferating across the globe – thinking advocates for more system-informed
including the creation of national-level decisions and processes across the health system.
4
knowledge translation platforms and institutes – These are highly complex though complementary
there is great scope for learning, alignment and processes that most certainly require deeper
even hybridization with systems thinking. Where understanding, further analysis and study.
BOX 4.6 INTERACTION BETWEEN RESEARCHERS

AND POLICY-MAKERS ON A ROAD
TRAFFIC POLICY IN MALAYSIA
In response to the alarming levels of road traffic injuries in Malaysia, the Department
of Road Safety within Malaysia's Ministry of Transport decided to develop and implement
various programmes and campaigns to address this problem. Even though there was little
local evidence to guide actual policy decisions, policy officials had a skeptical view
of research, believing it took too much time to conduct. They were also concerned that
research might demonstrate little actual impact of their proposed interventions (119).
Eventually, however, a team of researchers negotiated a mutually beneficial research
programme with the Department of Road Safety – one that satisfied the policy-makers’ need
to demonstrate action, and one that also produced the necessary evidence for decision-
making. Policy-makers saw the field trials of interventions as practical and necessary
to addressing the “how-to” questions surrounding implementation. The research-policy
partnership determined common goals and objectives, along with specific intervention options.
After some discussion, policy-makers wanted to develop and launch a national campaign
to promote the use of “visibility enhancement materials” – reflectors – though the researchers
were able to convince policy-makers to first launch a field trial to determine the efficacy
of reflectors. Discussion around the benefits of potentially negative research findings with
policy-makers was critical in convincing them to invest in research – if it were found that
reflectors were not effective, the field test would be much more cost-effective than a failed
nation-wide programme. This process has only strengthened the relationship between
researchers and policy-makers and provided the basis for future collaborative research into
practice in the country (119).
4
Examples include the Regional East African Community
Health Policy Initiative (REACH-Policy) based in Kampala,
Uganda; the Zambia Forum for Health Research
(ZAMFOHR), based in Lusaka, Zambia; and the Evidence-
Informed Policy Network (EVIPNet), a WHO initiative
based in Geneva, Switzerland that supports KT
in a variety of developing-world contexts.

4. Encouraging an increased Conclusion
national understanding of health
systems research and increased There are some formidable challenges facing –
global support for strengthening and even preventing – the full application of
capacity in health systems research a systems perspective in understanding and
solving weaknesses in developing country health
Crucially, systems thinking depends upon systems. This Chapter has discussed some of
an understanding of “the system” among key the more daunting challenges but also
stakeholders, and a wider appreciation of health highlighted important and innovative systems
systems research. There have been some recent thinking solutions and achievements. Clearly,
compelling developments in both, particularly there is a great deal of work yet to do, but
in renewed capacity strengthening efforts if systems thinking can turn the spotlight to
targeting researchers looking to sharpen their the leadership and commitment of system
skills in health systems research. These include: stewards, and to new partnerships across
n
the Consortium for Advanced Research the health system – from policy implementers
Training in Africa (CARTA). Based at to global funders – then it may very well open
the African Population and Health Research the next chapter in strengthening health systems.
Centre in Nairobi, Kenya, CARTA seeks Systems thinking, it should be remembered,
to boost the skills of doctoral students is not a panacea. It will not solve all of the stark
in health research, particularly through challenges to strengthening health systems
the acquisition of multi-disciplinary and KT in developing countries. However, it is one
skills; of several essential tools to restructuring
n
the Health Research Capacity Strengthening the relationships within the health system.
Initiative (HRCS). Now operating in both The more often and more comprehensively
Kenya and Malawi, HRCS aims to coordinate the actors and parts of the system can talk to
in-country health research and spearhead each other – communicating, sharing, problem-
capacity-building activities, particularly solving – the better chance any initiative to
in promoting career pathways for young strengthen health systems has. Real progress will
researchers. undoubtedly require time (92), significant
n
The Initiative to Strengthen Health Research change, and support for the present momentum
Capacity in Africa (ISHReCA). This network to build capacity across the system and
of health researchers looks to radical to promote multi-stakeholder approaches in
solutions to strengthen African capacity the design and evaluation of system-level
to conduct health research through new interventions. However, the change is necessary –
platforms to build and integrate capacity and needed now.
at the individual, institutional and system
levels.

5
systems strengthening:
Moving forward
"A system just can't respond to short-term changes
when it has long-term delays. That's why a massive
central-planning system ... necessarily functions poorly".
Donella Meadows, 1999 (53).
In this Report, we promote systems thinking

The growing focus
as a core approach to understand how health
on health systems interventions exert their system-wide effects
It has become commonplace in health and how this systems analysis can be used
development and global health initiatives to better design and evaluate interventions
to experience “system-wide barriers” to rapid in health systems.
attainment of global goals for health. Indeed, There has never been a better time for applying “The global health
systems thinking in health systems. Efforts agenda is shifting from
the weak performance of many health systems
an emphasis on
to deliver disease- or programme-specific to define health systems (83) have resulted disease-speciﬁc
goals continues to reinforce vertical solutions in comprehensive frameworks for the key approaches to a focus
that bypass systems. Yet the stewards of elements and building blocks of contemporary on strengthening of
health systems. ...Yet
national health systems must deal daily with health systems (83). Funding for health interven- clearly the disease-
their real-world challenges to build effective, tions and for health systems strengthening focused programmes
efficient, equitable and sustainable systems has increased substantially. Scaling up what are concerned about
shifts in global
to ensure national health goals. Fortunately works has become a main mandate of health
resources to health
everyone agrees that both trajectories (vertical system reforms in developing countries. At systems.” Takemi and
and horizontal) are focused on the same the same time, developed country health systems Reich, 2009 (120).
end, and that bringing them into a single have increasingly adopted systems thinking at
coherent approach would be mutually sub-system levels to tackle complex and large-
beneficial. Most global health initiatives now scale challenges such as major organizational
recognize the need to invest in health system systems (e.g. hospital systems (121), health
strengthening as a requisite for success. Most information systems (122)) or complex health
n a t i o n a l h e a l t h s y s t e m s t e wa r d s wa n t challenges (e.g. the tobacco (22), diabetes (27)
to leverage such investments in support and obesity epidemics (34)). This Report goes
of system-wide improvements. The question further and explores the opportunity to apply
though is how to do this. systems thinking to the health system as
a whole, and particularly to health system
strengthening interventions and their evaluation
in developing countries.
CHAPTER 5 MOVING FORWARD 89

BOX 5.1 S UMMARY OF THE TEN STEPS TO
SYSTEMS THINKING FOR HEALTH
SYSTEMS STRENGTHENING
I. Intervention Design II. Evaluation Design

1. Convene stakeholders 5. Determine indicators
2. Collectively brainstorm 6. Choose methods
3. Conceptualize effects 7. Select design
4. Adapt and redesign 8. Develop plan
9. Set budget
10. Source funding.
For more on the Ten Steps, please refer to Chapter 3.
In order to introduce systems thinking There is nothing completely original or unfamiliar

in a context that is often dominated by single in the Ten Steps. Some developing country system
disease and fragmented programme thinking, stewards may well be employing some or even
we have proposed ten sequential steps to begin all of the Ten Steps, using multi-disciplinary
solving complex system-level problems (see and multi-stakeholder teams. Rather than
Box 5.1). None of these steps should be alien proposing something that is totally new, this
to any practitioner in health systems research Report aims to make system-wide approaches
or development. But greater benefits emerge with all steps in sequence the norm – rather
from the synergies generated when all Ten Steps than the exception – and to promote better
are conducted in sequence. Applying the Ten documentation of those instances where
Steps opens the needed space to appreciate system-wide approaches to design and
and address complexity, connections, feedback evaluation have indeed been used. That said,
loops, time delays and non-linear relationships. examples of health system strengthening
that deliberately intervene simultaneously
in all six building blocks of a health system
Schools of thought and are uncommon, though when this has happened
experience large synergistic effects have resulted (Box 5.2).
Evaluating such effects in relation to a suite
This Report intends to be a primer and initiation
of interventions demands a full systems thinking
into systems thinking and to open windows
approach, not just to the interventions, but
on inspiring concepts and experiences. Though
also to the evaluation itself.
much of the systems thinking literature cited may
be unfamiliar to many, we encourage readers to
examine the provided reference list for deeper
insights into the systems thinking approach
for health.

BOX 5.2 EXAMPLE OF SYSTEM-WIDE EFFECTS
OF A SYSTEM-WIDE INTERVENTION
Health system strengthening interventions rarely include a suite of interventions applied

simultaneously to target each building block of the health system. One example of this is
the Tanzania Ministry of Health Essential Health Interventions Project (TEHIP). Launched
in 1996, TEHIP led to large synergistic health effects at the district level (123). It targeted
the Governance building block through district decentralization and increased ownership of
the planning process and fiscal resources; Financing through providing an untied district-level
SWAp (Sector Wide Approach) basket fund and through a district health accounts tool
for resource allocation; Information through providing annual district health profiles founded
on community-based sentinel surveillance systems and through radios to improve
communications among health facilities and managers; Human Resources through
empowering use of local basket funds for management training, communications, and other
means to improve team work and working conditions for new health interventions; Medicines
and Technologies through the ability to solve drug stock-outs by accessing the local basket
fund and increased authority to spend; and Service Delivery through early adoption
of new interventions such as Integrated Management of Childhood Illness and Insecticide
Treated Bed Nets.
All interventions were highly interdependent. The financing intervention was essential –
but funding alone would not have lead to such good performance outcomes (including a 40%
drop in under-five mortality seen within five years). Without the governance change allowing
decentralization of responsibility with greater authority for spending, little would have
changed. Without the new information sources that related spending priorities to health
priorities, the subsequent resource re-allocations (which resulted in service delivery change)
would not have occurred. Without the feedback on progress from their information system,
there would have been little idea of what was working, and what not. Without further
governance changes allowing ownership of planning and the flexibility to spend on human
resource training, the new and more powerful interventions would not have been adopted
so quickly.
It is impossible to say which of the interventions in this web were the most important.
The evaluation used a multi-institutional, multi-disciplinary, plausibility design that provided
compelling information for districts and policy-makers. Tanzania’s Ministry of Health scaled
up many of the innovations and lessons learnt in TEHIP in 2000 with similar strong effects
seen at the national level by 2004 (124).

In this Report, we have taken the case of 4) inspire learning; and
a major contemporary system-level intervention 5) foster more system-wide planning, evaluation
to show how – using the first four of the Ten and research.
Steps – a stronger partnership of stakeholders
For the community that this Report primarily
can deliver a richer understanding of
addresses (health system stewards, researchers
the implications of the intervention. This in turn
and funders interested in health systems
creates a greater sense of ownership, and
strengthening in low-income settings) the
a more robust intervention design with a greater
following are some reflections on possible actions
chance to maximize synergies and mitigate
or next steps to deepen and develop systems
unintended negative effects. The remaining
thinking for health systems strengthening.
steps illustrate how the research and evaluation
community can contribute to verify the design Task Force on Systems Thinking for
and fine-tune it over time. Such approaches Health Systems. Extending a systems thinking
to intervention and evaluation are infrequent, movement and culture requires a number of
and when proposed, are rarely funded. So what combined initiatives. Convening a temporary task
is the way forward in mainstreaming the systems force or think tank engaging key practitioners
perspective? from the health systems thinking community –
together with key stakeholders for health system
strengthening – may be one way to achieve
Moving forward this. Such a Task Force could, for example,
be convened under the auspices of the WHO
Not surprisingly, practitioners of systems thinking
Health Systems Department and the Alliance
have considered the actions required to build
for Health Policy and Systems Research
capacity for the systems perspective. These
with the support of other interested parties.
typically centre on the creation of a systems
thinking environment conducive to a strong Systems Thinking network or
orientation to team science and development. communities of practice. A natural
The approaches generally include: developing s p i n - o f f f r o m t h e Ta s k Fo r c e w o u l d b e
and applying systems methods and processes; the development of a network or community
building system knowledge capacity; building of practice around systems thinking for health
and maintaining network relationships; and systems. These would of course include country
encouraging a systems culture (29). implementers and donors. This could deepen
There are, of course, practical challenges to the skills of systems thinking, enable strong
introducing and applying systems thinking in horizontal learning among systems thinkers,
the health sector (33). Systems thinkers have be a resource for newcomers, and fine-tune
conceptually mapped these. They include the Ten Steps. Emerging networks could tackle
the need to work along the following lines: many of the issues listed below.
1) explore problems from a systems perspective; Building the capacity of system

2) show potentials of solutions that work stewards. A special case of the community
across sub-systems; of practice might be the issue of building
capacity among policy-makers for systems
3) promote dynamic networks of diverse
stakeholders; thinking. This could entail the creation of policy
briefs or briefing notes that provide short,

digestible descriptions of best practice. One of Expanding Systems Thinking in
the core actions of the Task Force, and supported schools of public health and degrees
b y m e m b e r s o f t h e n e t w o r k s, c o u l d b e in health systems management.
developing capacity-building courses for system Some schools of international public health have
stewards which could draw upon other successful already started to introduce systems theory
models of training policy-makers (e.g. the in their curricula. The communities of practice
Executive Training for Research Application as presented above may support and promote
(EXTRA) programme offered by the Canadian these programs for a new generation of public
Health Services Research Foundation). health expertise.
Systems Thinking conference for best Applying the Ten Steps. A consortium
practices . There is a growing body of of health system stakeholders, researchers
experience in applying systems thinking at and development donors could be assembled
the sub-system or building-block level, but for testing the Ten Steps proposed here with
no international forum to bring those experiences regard to the large new initiatives that are
together in a peer environment for further emerging for health systems strengthening
development and catalysis. A conference initiatives (e.g. from the G8, International Health
or similar event could be an early action Partnership+, Global Fund to fight AIDS,
supported by the Task Force or networks, Tuberculosis and Malaria, Global Alliance
to further convene the community of practice for Vaccines and Immunization, and so on).
to focus in particular on sharing experiences A Journal of Systems Thinking for
and methods development. Health. There are very few open-source,
Systems Thinking methods. Continued peer-reviewed journals dedicated to health
development of conceptual approaches and systems development. Moreover, health
methods is a constant need. The Task Force, systems research of the nature demanded by
networks and conference will be critical systems thinking (for example when multiple
to identifying these needs, breaking down interventions with multiple effects are to
the “silos,” and driving the development agenda be described) will suffer from the publication
forward. bias against long papers. This also affects
health systems research from a systems-wide
Health systems dynamic modeling. There
perspective. A dedicated journal for health
is increasing interest and activity in dynamic
systems with a focus on Systems Thinking
modeling to forecast the effects of new health
for Health will be a timely addition.
interventions in disease-specific contexts
(e.g. malaria vaccines) (125;126). The larger
these modeling projects become, the more
the modelers realize they must integrate
modeling of health service delivery and health
systems. This greatly increases the complexity
of their models, but will be of particular use to
the systems dynamics and modeling demands
of system thinking. These efforts could be
networked and could contribute immensely
to health system design (33;127).

Wrapping up
These are exciting times for health systems Future health systems will undoubtedly
strengthening. The opportunities are immense, be anchored in dynamic, strongly designed,
yet so too are the challenges. More of the same and decidedly systemic architecture. These
will not suffice to achieve the ambitious goals will be systems capable of high performance
that have been set. Beyond system-centered in producing health with equity. The question
approaches, we need continual innovation – is how to accelerate progress to that end.
achieved not through a radical departure from We hope this Report of the Alliance stimulates
the past but by creatively combining past both fresh thinking and concrete action towards
experience. This Report contributes to this effort such stronger health systems.
by exploring the huge potential of systems As always, the final message is to the funders
t h i n k i n g i n d e s i g n i n g o u r wa y f o r wa r d of health system strengthening and health
to stronger health systems, and to evaluating systems research who will need to recognize
how that progress is achieved. The Report the potential in these opportunities, be prepared
identifies systems thinking as a hugely valuable to take risks in investing in such innovations,
but under-exploited approach. We introduce and play an active role in both driving and
the concepts, and discuss what they can mean following this agenda towards more systemic
for health systems strengthening. We draw and evidence-informed health development.
on emerging successes from the application
of systems thinking at smaller scales and
propose ways in which it can be applied
at the scales now being addressed in many
developing country health systems. We have
shown what it might look like using illustrations
from highly contemporary interventions. We have
explored the challenges and sketch some steps
for the way forward to harness these approaches
and link them to these emerging opportunities.

Reference List
(1) U n i t e d N a t i o n s. Th e M i l l e n n i u m (10) Yu D et al. Investment in HIV/AIDS
Development Goals Report 2009. New programs: Does it help strengthen health
York, United Nations, 2009. systems in developing countries?
Globalization and Health, 2008, 4:8.
(2) Bryce J et al. Countdown to 2015: tracking
intervention coverage for child survival. (11) Hanefeld J. How have Global Health
Lancet, 2006, 368(9541):1067-1076. Initiatives impacted on health equity?
Promotion & Education, 2008, 15(1):19-
(3) Victora CG et al. Co-coverage of preventive
23.
interventions and implications for child-
survival strategies: evidence from national (12) Schieber GJ et al. Financing global health:
surveys. Lancet, 2005, 366(9495):1460- mission unaccomplished. Health Affairs,
1466. 2007, 26(4):921-934.
(4) Kruk ME, Freedman LP. Assessing health (13) Murray CJ, Frenk J, Evans T. The Global
system performance in developing Campaign for the Health MDGs: challenges,
countries: A review of the literature. Health opportunities, and the imperative of shared
Policy, 2007, 85(3): 263-276. learning. Lancet, 2007, 370(9592):1018-
1020.
(5) World Health Organization. Everybody's
Business: Strengthening Health Systems to (14) Buse K, Walt G. Globalisation and multi-
Improve Health Outcomes: WHO's lateral public-private health partnerships:
Framework for Action. Geneva, WHO, issues for health policy. In: K Lee, S
2007. Fustukian, K Buse, editors. Health Policy
in a Globalising World. Cambridge,
(6) Travis P et al. Overcoming health-systems
Cambridge University Press, 2007.
constraints to achieve the Millennium
Development Goals. Lancet, 2004, (15) Lu C et al. Absorptive capacity and
364(9437):900-906. disbursements by the Global Fund to Fight
AIDS, Tuberculosis and Malaria: analysis
(7) Tu g w e l l P e t a l . A p p l y i n g c l i n i c a l
of grant implementation. Lancet, 2006,
epidemiological methods to health equity:
368(9534):483-488.
the equity effectiveness loop. BMJ, 2006,
332(7537):358-361. (16) Labonte R, Schrecker T. The G8 and global
health: What now? What next? Canadian
(8) World Health Organization Maximizing
Journal of Public Health, 2006, 97(1):35-
Positive Synergies Collaborative Group.
38.
An assessment of interactions between
global health initiatives and country health (17) Pawson R et al. Realist review – a new
systems. Lancet, 2009, 373(9681):2137- method of systematic review designed
2169. for complex policy interventions. Journal
of Health Services Research & Policy, 2005,
(9) B a n a t i P, M o a t t i J P. Th e p o s i t i v e
10 Suppl 1:21-34.
contributions of global health initiatives.
Bulletin of the World Health Organization,
2008, 86(11):820.
REFERENCE LIST SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING 97

(18) Golden BR, Martin RL. Aligning the stars: (26) Shiell A, Hawe P, Gold L. Complex
Using systems thinking to (re)design interventions or complex systems?
Canadian healthcare. Healthcare Quarterly, Implications for health economic
2004, 7(4):34-42. evaluation. BMJ, 2008, 336(7656):1281-
1283.
(19) Plsek PE, Greenhalgh T. Complexity
science: The challenge of complexity (27) Kalim K, Carson E, Cramp D. An illustration
in health care. BMJ, 2001, 323(7313):625- of whole systems thinking. Health Services
628. Management Research, 2006, 19(3):174-
185.
(20) World Health Organization. People at
the centre of health care: harmonizing (28) Richmond B. The "thinking" in systems
mind and body, people and systems. thinking: Seven essential skills. Waltham
Geneva, WHO, 2007. MA, Pegasus Communications, 2000.
(21) World Health Organization. Primary Health (29) Leischow SJ et al. Systems thinking
Care: Now more than ever. Geneva, WHO, to improve the public's health. American
2008. Journal of Preventive Medicine, 2008,
35(2 Suppl):S196-S203.
(22) Best A et al. Greater than the sum:
Systems thinking in tobacco control. (30) Pickett RB, Kennedy MM. Systems thinking
Bethesda, MD, National Cancer Institute, and managing complexity, Part two. Clinical
US Department of Health and Human Leadership Management Review, 2003,
Services, National Institutes of Health, 17(2):103-107.
2007.
(31) Pickett RB, Kennedy MM. Systems thinking
(23) Office of Social and Behavioural Sciences and managing complexity, Part One. Clinical
Research. Contributions of Behavioral and Leadership Management Review, 2003,
Social Sciences Research to Improving 17(1):34-38.
the Health of the Nation: A Prospectus
(32) Sterman JD. Learning from evidence
for the Future. US Department of Health
in a complex world. American Journal
and Human Services, National Institutes
of Public Health, 2006, 96(3):505-514.
of Health, 2007.
(33) Trochim WM et al. Practical challenges
(24) Health Metrics Network. Framework and
of systems thinking and modeling in public
standards for country health information
health. American Journal of Public Health,
systems. 2nd ed. Geneva, World Health
2006, 96(3):538-546.
Organization, 2008.
(34) Butland B et al. Foresight: Tackling
(25) Craig P et al. Developing and evaluating
Obesities: Future Choices. London, UK
complex interventions: the new Medical
Government Office for Science, 2007.
Research Council guidance. BMJ 2008,
337:a1655.

(35) Finegood DT, Karanfil O, Matteson CL. (44) The Lancet. Data fraud in: This week in
Getting from analysis to action: Framing Medicine. Lancet, 2009, 373[9671], 1222.
obesity research, policy and practice with
(45) Adam T et al. Capacity constraints to
a solution-oriented complex systems lens.
the adoption of new interventions:
Healthcare Papers, 2008, 9(1):36-41.
consultation time and the integrated
(36) Shiell A. The danger in conservative framing management of childhood illness in Brazil.
o f a c o m p l e x , s y s t e m s - l e v e l i s s u e. H e a l t h Po l i c y & P l a n n i n g , 2 0 0 4 ,
Healthcare Papers, 2008, 9(1):42-45. 20(Suppl 1):i49-i57.
(37) Atun R, Menabde N. Health systems and (46) Kamuzora P, Gilson L. Factors influencing
systems thinking. In: Coker R, Atun R, implementation of the Community Health
McKee M, editors. Health systems and Fund in Tanzania. Health Policy & Planning,
the challenge of communicable disease: 2007, 22(2):95-102.
Experience from Europe and Latin America.
(47) International Health Partnership. Annual
Berkshire, Open University Press, 2009:
Monitoring and Evaluation of the Inter-
122-140.
national Health Partnership & related
(38) Holden LM. Complex adaptive systems: Initiatives (IHP+). WHO, 2009.
concept analysis. Journal of Advanced
(48) Shiell A, Riley T. Theorizing interventions
Nursing, 2005, 52(6):651-657.
as events in systems. American Journal
(39) Rickles D, Hawe P, Shiell A. A simple guide of Community Psychology, 2009,
to chaos and complexity. Journal of 43(3):267-276.
Epidemiology and Community Health,
(49) Hawe P, Bond L, Butler L. Knowledge
2007, 61(11):933-937.
theories can inform evaluation practice.
(40) Bierema LL. Systems thinking: a new lens What can a complexity lens add? New
for old problems. Journal of Continuing Directions in Evaluation, 2009;
Education in the Health Professions, 2003, in press.
23 Suppl 1:S27-S33.
(50) Hawe P, Ghali L. Use of social network
(41) World Bank. Healthy Development: analysis to map the social relationships
The World Bank Strategy for Health of staff and teachers at school. Health
Nutrition and Population Results: Annex L. Education Research, 2008, 23(1):62-69.
World Bank, 2007.
(51) Hawe P et al. Methods for exploring imple-
(42) Meadows D, Richardson J, Bruckmann G. mentation variation and local context
Groping in the dark: the first decade within a cluster randomised community
of global modelling. New York, NY, Wiley, intervention trial. Journal of Epidemiology
1982. and Community Health, 2004, 58(9):788-
793.
(43) M e a d o w s D. Th i n k i n g i n s y s t e m s :
A primer. White River, VT, Sustainability (52) O'Conner J, McDermott I. The Art of Systems
Institute, 2008. Thinking: Essential Skills for Creativity and
Problem-Solving. San Francisco, CA,
Thorsons Publishing, 1997.

(53) Meadows D. Leverage Points: Places (62) Liu X, Mills A. The influence of bonus
to Intervene in a System. White River, VT, payments to doctors on hospital revenue:
The Sustainability Institute, 1999. results of a quasi-experimental study.
Applied Health Economics and Health
(54) Leischow SJ, Milstein B. Systems thinking
Policy, 2003, 2(2):91-98.
and modeling for public health practice.
American Journal of Public Health, 2006, (63) Soeters R, Habineza C, Peerenboom PB.
96(3):403-405. Performance-based financing and
changing the district health system:
(55) Atun RA et al. Introducing a complex
experience from Rwanda. Bulletin of
health innovation – primary health
the World Health Organization, 2006,
care reforms in Estonia (multimethods
84(11):884-889.
e va l u a t i o n ) . H e a l t h Po l i c y , 2 0 0 6 ,
79(1):79-91. (64) Lagarde M, Haines A, Palmer N. Conditional
cash transfers for improving uptake of
(56) Atun RA et al. Diffusion of complex health
health interventions in low- and middle-
innovations – implementation of primary
income countries: a systematic review.
health care reforms in Bosnia and
JAMA, 2007, 298(16):1900-1910.
Herzegovina. Health Policy & Planning,
2007, 22(1):28-39. (65) Brugha R, Varvasovszky Z. Stakeholder
analysis: a review. Health Policy &
(57) Campbell NC et al. Designing and
Planning, 2000, 15(3):239-246.
evaluating complex interventions to
i m p r o v e h e a l t h c a r e. B M J , 2 0 0 7 , (66) Schmeer K. Stakeholder analysis
334(7591):455-459. guidelines. Bethesda, USA, Abt Associates,
1999.
(58) Craig P et al. Developing and evaluating
complex interventions: new guidance. (67) Campbell M et al. Framework for design
Medical Research Council, 2009. and evaluation of complex interventions to
improve health. BMJ, 2000, 321:694-696.
(59) Casalino LP et al. Will pay-for-performance
and quality reporting affect health care (68) Graham A et al. Translating cancer control
disparities? Health Affairs, 2007, research into primary care practice:
26(3):w405-w414. a conceptual framework. American Journal
of Lifestyle Medicine, 2008, 2:241-248.
(60) Eichler R. Can Pay for Performance
increase utilisation by the poor and (69) Victora CG et al. Context matters:
improve quality of health services. interpreting impact findings in child
Discussion Paper. Washington DC, Centre survival evaluations. Health Policy &
for Global Development, 2006. Planning, 2005, 20(suppl_1):i18-i31.
(61) Johannes L et al. Performance-based (70) Baltussen R, Leidl R, Ament A. Real world
contracting in health. The experience designs in economic evaluation. Bridging
in three projects in Africa. OBA the gap between clinical research and
Approaches [19]. The Global Partnership policy-making. Pharmacoeconomics, 1999,
for Output-based Aid, 2009. 16(5 Pt 1):449-458.

(71) Lemmer B, Grellier R, Steven J. Systematic (79) Victora C, Habicht J-P, Bryce J. Evidence-
review of nonrandom and qualitative based public health: Moving beyond
research literature: exploring and randomized trials. American Journal
uncovering an evidence base for health of Public Health, 2004, 94(3):400-415.
visiting and decision making. Qualitative
(80) Hanson K et al. Household ownership
Health Research, 1999, 9(3):315-328.
and use of insecticide treated nets among
(72) Hawe P, Shiell A, Riley T. Complex target groups after implementation
interventions: how "out of control" can of a national voucher programme in
a randomised controlled trial be? BMJ, t h e U n i t e d R e p u b l i c o f Ta n z a n i a :
2004, 328(7455):1561-1563. plausibility study using three annual cross
sectional household surveys. BMJ, 2009,
(73) B o n e l l C P e t a l . A l t e r n a t i v e s t o
339(jul02_1):b2434.
randomisation in the evaluation of public-
health interventions: design challenges (81) Hanson K et al. Vouchers for scaling up
and solutions. Journal of Epidemiology insecticide-treated nets in Tanzania:
and Community Health, 2009 [epub ahead Methods for monitoring and evaluation of
of print]. a national health system intervention.
BMC Public Health, 2008, 8(1):205.
(74) King G et al. Public policy for the poor?
A randomised assessment of the Mexican (82) Richmond B. Systems Thinking: Four Key
universal health insurance programme. Questions. High Performance Systems Inc.,
Lancet, 2009, 373(9673):1447-1454. 1991.
(75) Black N. Why we need observational (83) World Health Organization. The World
studies to evaluate the effectiveness of Health Report 2000: Health systems:
health care. BMJ, 1996, 312:1215-1218. Improving performance. Geneva, World
Health Organization, 2000.
(76) Smith PG, Morrow RH. Field trials of health
interventions in developing countries. 2nd (84) Hanefeld J, Musheke M. What impact do
Edition. London: Macmillan, 1996. Global Health Initiatives have on human
resources for antiretroviral treatment roll-
(77) Habicht JP, Victora CG, Vaughan JP.
out? A qualitative policy analysis of
E v a l u a t i o n d e s i g n s f o r a d e q u a c y,
implementation processes in Zambia.
plausibility and probability of public health
Human Resources for Health, 2009, 7.
programme performance and impact.
International Journal of Epidemiology, (85) Organization for Economic Co-operation
1999, 28(1):10-18. and Development. 2008 Survey on
Monitoring the Paris Declaration – Making
(78) Habicht JP, Victora CG, Vaughan JP.
Aid more Effective by 2010. Paris, OECD,
A framework for linking evaluation needs
2009.
to design choices – with special reference
to the fields of health and nutrition.
UNICEF,1997.

(86) Marchal B, Cavalli A, Kegels G. Global (95) Walker L, Gilson L. 'We are bitter but we
Health Actors Claim To Support Health are satisfied': nurses as street-level
System Strengthening – Is This Reality or bureaucrats in South Africa. Social Science
Rhetoric? PLoS Medicine, 2009, 6(4):1-5. & Medicine, 2004, 59(6):1251-1261.
(87) S a m b B e t a l . A n a s s e s s m e n t o f (96) Kaler A, Watkins SC. Disobedient

interactions between global health distributors: Street-level bureaucrats and
initiatives and country health systems. would-be patrons in community-based
Lancet, 2009, 373(9681):2137-2169. family planning programs in rural Kenya.
Studies in Family Planning, 2001,
(88) A s s e f a Y e t a l . R a p i d s c a l e - u p o f
32(3):254-269.
antiretroviral treatment in Ethiopia:
successes and system-wide effects. PLoS (97) Lipsky M. Street-level Bureaucracy:
Medicine, 2009, 6(4):e1000056. Dilemmas of the Individual in Public
S e r v i c e s . N e w Yo r k , R u s s e l l S a g e
(89) Biesma RG et al. The effects of global
Foundation, 1980.
health initiatives on country health
systems: a review of the evidence from (98) The Commission on Health Research
HIV/AIDS control. Health Policy & Planning, for Development. Health research:
2009, 24(4):239-252. Essential link to equity in development.
New York, Oxford University Press,
(90) Travis P, Bennett S, Haines A. Overcoming
1990.
health-systems constraints to achieve
the millennium development goals. Lancet, (99) Victora CG, Habicht JP, Bryce J. Evidence-
2005, 365(9456):294. based public health: moving beyond
randomized trials. American Journal
(91) Oomman N, Bernstein M, Rosenzweig S.
of Public Health, 2004, 94(3):400-405.
Seizing the opportunity on AIDS and
health systems. Washington DC, Centre for (100) Bennett S et al. From Mexico to Mali:
Global Development, 2008. progress in health policy and systems
research. Lancet, 2008, 372(9649):1571-
(92) Organization for Economic Co-operation
1578.
and Development. Paris Declaration on Aid
Effectiveness. Paris, OECD, 2005. (101) White F. Capacity-building for health
research in developing countries:
(93) Global Fund to fight AIDS, TB and Malaria.
a manager's approach. Pan American
Scaling up for impact: Results report 2008.
Journal of Public Health, 2002, 12(3):165-
Executive summary. Geneva, GFATM,
172.
2009.
(102) The Global Ministerial Forum on Research
(94) Penn-Kekana L, Blaauw D, Schneider H. 'It
for Health. The Bamako call to action
makes me want to run away to Saudi
on research for health. Geneva, Global
Arabia': management and implementation
Ministerial Forum on Research for Health,
challenges for public financing reforms
2008.
from a maternity ward perspective. Health
Policy & Planning, 2004, 19:I71-I77.

(103) C o u n c i l o n H e a l t h R e s e a r c h f o r (111) Bowen S, Zwi AB. Pathways to "evidence-
Development (COHRED). Supporting informed" policy and practice:
national health research systems in low A framework for action. PLoS Medicine,
and middle income countries. Annual 2005, 2(7):600-605.
Report 2008. Geneva, COHRED, 2008.
(112) Lomas J. Using research to inform
(104) Harris E. Building scientific capacity healthcare managers' and policy makers'
in developing countries. EMBO Reports, questions: from summative to interpretive
2004, 5(1):7-11. synthesis. Healthcare Policy, 2005,
1(1):55-71.
(105) Rathgeber EM. Research partnerships in
international health: Capitalizing on (113) Hamid M et al. EVIPNet: translating
opportunity. Stakeholders' Meeting Berlin, the spirit of Mexico. Lancet, 2005,
16-18 March 2009, Research Partnership 366(9499):1758-1760.
for Neglected Diseases of Poverty.
(114) Innvaer S et al. Health policy-makers'
(106) International Development Research perceptions of their use of evidence:
Centre. Working together to strengthen a systematic review. Journal of Health
skills – IDRC's strategic evaluation Services Research & Policy, 2002,
of capacity development, phase 3: 7(4):239-244.
Developing the framework. Ottawa,
(115) Lavis JN et al. Assessing country-level
International Development Research
efforts to link research to action. Bulletin
Centre, 2007.
of the World Health Organization, 2006,
(107) Pfeiffer J, Nichter M. What can critical 84(8):620-628.
medical anthropology contribute to global
(116) Court J, Hovland I, Young J. Bridging
health? A health systems perspective.
research and policy in international
Medical Anthropology Quarterly, 2008,
development. London, ITDG Publishing,
22(4):410-415.
2004.
(108) Gilson L, Raphaely N. The terrain of health
(117) Stone D, Maxwell M. Global Knowledge
policy analysis in low and middle income
networks and international development:
countries: a review of published literature
bridges across boundaries. Routledge,
1994-2007. Health Policy & Planning,
2005.
2008, 23(5):294-307.
(118) Green A, Sara Bennett, eds. Sound Choices:
(109) Trochim WMK. An Introduction to Concept
enhancing capacity for evidence-informed
Mapping for Planning and Evaluation.
health policy. Geneva, Alliance for Health
Evaluation and Program Planning, 1989,
Policy and Systems Research, WHO, 2007.
12(1):1-16.
(119) Hyder AA et al. Integrating ethics, health
(110) Lavis JN et al. Evidence-informed health
policy and health systems in low- and
policy 4 – Case descriptions of
middle-income countries: case studies from
organizations that support the use of
Malaysia and Pakistan. Bulletin of
research evidence. Implementation
the World Health Organization, 2008,
Science, 2008, 3:56.
86(8):606-611.

(120) Reich MR, Takemi K. G8 and strengthening
of health systems: follow-up to the Toyako
summit. Lancet, 2009, 373(9662):508-
515.
(121) Holland C, Lien J. Systems thinking:

managing the pieces as part of the whole.
Clinical Leadership Management Review,
2001, 15(3):153-157.
(122) Rothschild AS et al. Leveraging systems

thinking to design patient-centered
c l i n i c a l d o c u m e n t a t i o n s y s t e m s.
International Journal of Medical
Information, 2005, 74(5):395-398.
(123) d e S a v i g n y D e t a l . F i x i n g H e a l t h
Systems. 2nd Edition. Ottawa,
International Development Research
Centre, 2008.
(124) Masanja H et al. Child survival gains

in Tanzania: analysis of data from
demographic and health surveys. Lancet,
2008, 371(9620):1276-1283.
(125) Homer JB, Hirsch GB. System dynamics

modeling for public health: background
and opportunities. American Journal
of Public Health, 2006, 96(3):452-458.
(126) Smith T et al. Towards a comprehensive

simulation model of malaria epidemiology
and control. Parasitology, 2008, 1-10.
(127) Sanderson C, Gruen RL. Analytical models

for decision making. Open University
Press, 2006.

Alliance Board members Alliance Scientific
Jonathan Broomberg and Technical Advisory
Discovery Health, Sandton, South Africa
Committee members
Barbro Carlsson
Department for Research Cooperation at the Irene Akua Agyepong
Swedish International Development Cooperation Ghana Health Service, Accra, Ghana
Agency, Stockholm, Sweden
Lucy Gilson
Somsak Chunharas University of Cape Town, South Africa
National Health Foundation, Bangkok, Thailand Health Policy and Systems, London School of
Hygiene and Tropical Medicine, United Kingdom
Carissa Etienne
World Health Organization, Geneva, Switzerland Sennen Hounton
WHO Multi Disease Surveillance Center,
Stephen Matlin Ouagadougou, Burkina Faso
Global Forum for Health Research, Geneva,
Switzerland Soonman Kwon
Department of Health Policy and Management,
Anne Mills, Chair School of Public Health, Seoul National
London School of Hygiene and Tropical Medicine, University, South Korea
London, United Kingdom
John Lavis
Sania Nishtar McMaster University, Hamilton, Canada
Heartfile, Islamabad, Pakistan
John-Arne Röttingen Prasanta Mahapatra

Norwegian Knowledge Centre for the Health Government of Andhra Pradesh, India
Services, Oslo, Norway Institute of Health Systems, India
Göran Tomson
Sameen Siddiqi Karolinska Institute, Stockholm, Sweden
World Health Organization, Eastern Mediter-
ranean Regional Office,Cairo, Egypt
Saul Walker
Policy and Research Division, Department for
International Development, United Kingdom
The Alliance gratefully acknowledges funding from the Department for International Development (DFID,
United Kingdom), the Australian Government's overseas aid program (AusAID), the International
Development Research Center (IDRC, Canada), the Government of Norway, Sida-SAREC (Sweden) and
the Wellcome Trust (United Kingdom).
SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING 105

Notes

Notes
SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING 107

SYSTEMS "The responses of many health systems so far have
been generally considered inadequate and naïve.
THINKING ... a system's failure requires a system's solution –
not a temporary remedy."
for Health Systems (WHO World Health Report, 2008).
Strengthening
Systems Thinking for Health Systems Strengthening investigates how
systems thinking can deepen the conceptual and practical
underpinnings of system strengthening initiatives. This Flagship Report
from the Alliance for Health Policy and Systems Research makes
the case for systems thinking in an easily accessible form for a broad
interdisciplinary audience, including health system stewards, programme
implementers, researchers, evaluators and funding partners.
It presents:
What systems thinking is, and what it means for the health system
n
A health systems case illustration that demonstrates the “Ten Steps

n
to Systems Thinking” – practical guidance in applying the systems
perspective
The challenges and opportunities to applying systems thinking
n
in real-world settings
An agenda for expanding the use of systems thinking for health
n
systems strengthening.
World Health Organization

Avenue Appia 20
CH-1211 Genève 27
Switzerland
ISBN 978 92 4 156389 5
Tel.: +41 22 791 29 73

Fax: +41 22 791 41 69
alliance-hpsr@who.int
http://www.who.int/alliance-hpsr

WHO Systems Thinking 9789241563895 - Eng

Hochgeladen von

Dokumentinformationen

Originalbeschreibung:

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

WHO Systems Thinking 9789241563895 - Eng

Hochgeladen von

Copyright:

Verfügbare Formate

SYSTEMS

ISBN 978 92 4 156389 5 (NLM classification: W 84)

© World Health Organization 2009

2 SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

Executive Summary ......................................................................................................................................... 19

Reference List .............................................................................................................................................. 95

Alliance Board members ........................................................................................................................105

Alliance Scientific and Technical Advisory Committee members ..........................................105

6 SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

Box 2.1 Common systems characteristics ......................................................................................................... 40

Box 3.1 A pay-for-performance intervention – An illustrative example .............................................................. 52

Box 4.1 Select challenges in applying a systems perspective ............................................................................ 75

8 SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

Editors: Don de Savigny and Taghreed Adam

Chapter 5. Systems thinking for health systems strengthening: Moving forward

TEN STEPS TO SYSTEMS THINKING IN THE HEALTH SYSTEM

Challenges, Opportunities and Moving Forward

20 SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

Introduction to the Report

BOX 1.1 GOALS OF THIS REPORT

30 SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

The WHO Health System Framework

HEALTH WORKFORCE IMPROVED HEALTH

32 SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

Systems thinking is an approach to problem need a systems thinking approach. However,

SCALE-UP ANTIRETROVIRAL THERAPY

INTEGRATE VOUCHERS FOR MALARIA

INCREASING SYSTEM-WIDE EFFECTS

34 SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

effect approaches. Primarily aimed at intervention

36 SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

Using a systems perspective to understand how health system

Mainstreaming a stronger systems perspective in the health

Systems thinking offers a comprehensive way of anticipating

Objectives of the Chapter Systems thinking

CHAPTER 2 WHAT IT IS AND WHAT IT MEANS FOR HEALTH SYSTEMS 39

Most systems, including health systems, are:

systems (Box 2.2). The building block framework

BOX 2.2 SYSTEM BEHAVIOUR

40 SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

CHAPTER 2 WHAT IT IS AND WHAT IT MEANS FOR HEALTH SYSTEMS 41

42 SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

Table 2.1 Skills of systems thinking

Usual approach Systems thinking approach

Static thinking Dynamic thinking

Focusing on particular events Framing a problem in terms of a pattern

Systems-as-effect thinking System-as-cause thinking

Viewing behaviour generated by a system Placing responsibility for a behaviour on

Tree-by-tree thinking Forest thinking

Factors thinking Operational thinking

Listing factors that influence or correlate Concentrating on causality and under-

Straight-line thinking Loop thinking

Viewing causality as running in one Viewing causality as an on-going process,

Modified from Richmond, 2000 (28).

CHAPTER 2 WHAT IT IS AND WHAT IT MEANS FOR HEALTH SYSTEMS 43

BOX 2.4 SYSTEM STAKEHOLDER NETWORKS

The concept of “multi-finality” shows how stakeholder perspectives on the health

Modified from Wikipedia: Systems thinking (http://en.wikipedia.org/wiki/Systems_thinking). Accessed

44 SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

Systems Understanding and managing system stakeholders; the web of all

Systems Conceptually modeling and understanding dynamic change; attempting

Modified from Best et al, 2007 (22).